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Adherence to an Early Exercise Plan Promotes Visceral Fat Loss in the First Month Following Bariatric Surgery

Authors:
Johanna Pino-Zuñiga
Johanna Pino-Zuñiga
Johanna Pino-Zuñiga
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Paloma Lillo at Universidad Católica Silva Henríquez
Paloma Lillo
Mariela Olivares-Galvez
Mariela Olivares-Galvez
Mariela Olivares-Galvez
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Ana Palacio-Aguero
Ana Palacio-Aguero
Ana Palacio-Aguero
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Abstract and Figures

Background The evidence supporting the benefits of early exercise in post-bariatric patients is growing. This study analyzed the effects of early exercise (1-week post-bariatric surgery) on body composition in patients with overweight and obesity 1 month after surgery. Methods Thirty patients (age 36.5 ± 12.3 [range, 18–65] years; body mass index [BMI], 36.2 ± 12.3 kg/m², range, 29–48) who underwent laparoscopic sleeve gastrectomy for bariatric surgery were instructed to participate in an exercise training program initiated on day 3 post-surgery and to follow a recommended protein intake of 60 g/day. After 1-month post-surgery, patients were stratified into those who adhered to exercise recommendations and those who did not. Pre- and post-differences in total weight loss (TWL), skeletal muscle mass (SMM), fat mass (FM), and visceral fat mass (VFM) were compared. Results TWL, SMM, and FM loss were similar between non-adherent and adherent subjects (10.2 ± 3.5 kg and 11.9 ± 3.6 kg; p = 0.2; 2.9 ± 1.0 kg and 3.2 ± 1.2; p = 0.2; 6.2 ± 2.1 kg and 7.5 ± 3.6 kg; p = 0.2, respectively), whereas VFM was markedly reduced in the adherent group (29.9 ± 18.2 cm² vs 14.6 ± 9.4 cm²; p = 0.01) compared to the non-adherent group. When the group was divided according to adherence to exercise and protein intake or non-adherence to both conditions, there was a significant difference in TWL, FM, and VFM losses (p < 0.05). In contrast, no differences in SMM were found. Conclusions Early exercise training accelerated visceral fat mass loss during the initial recovery period in patients after bariatric surgery. Additionally, adherence to daily protein intake recommendations can increase total body weight and fat mass loss.
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Vol:.(1234567890)
Obesity Surgery (2025) 35:746–754
https://doi.org/10.1007/s11695-025-07685-z
RESEARCH
Adherence toanEarly Exercise Plan Promotes Visceral Fat Loss
intheFirst Month Following Bariatric Surgery
JohannaPino‑Zuñiga1· PalomaLillo‑Urzua2· MarielaOlivares‑Galvez1· AnaPalacio‑Aguero1,3·
JuanCamiloDuque1· RafaelLuengas1· JorgeCancino‑Lopez4,5
Received: 9 September 2024 / Revised: 6 January 2025 / Accepted: 11 January 2025 / Published online: 14 February 2025
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2025
Abstract
Background The evidence supporting the benefits of early exercise in post-bariatric patients is growing. This study analyzed
the effects of early exercise (1-week post-bariatric surgery) on body composition in patients with overweight and obesity
1month after surgery.
Methods Thirty patients (age 36.5 ± 12.3 [range, 18–65] years; body mass index [BMI], 36.2 ± 12.3kg/m2, range, 29–48)
who underwent laparoscopic sleeve gastrectomy for bariatric surgery were instructed to participate in an exercise training
program initiated on day 3 post-surgery and to follow a recommended protein intake of 60g/day. After 1-month post-surgery,
patients were stratified into those who adhered to exercise recommendations and those who did not. Pre- and post-differences
in total weight loss (TWL), skeletal muscle mass (SMM), fat mass (FM), and visceral fat mass (VFM) were compared.
Results TWL, SMM, and FM loss were similar between non-adherent and adherent subjects (10.2 ± 3.5kg and 11.9 ± 3.6kg;
p = 0.2; 2.9 ± 1.0kg and 3.2 ± 1.2; p = 0.2; 6.2 ± 2.1kg and 7.5 ± 3.6kg; p = 0.2, respectively), whereas VFM was markedly
reduced in the adherent group (29.9 ± 18.2 cm2 vs 14.6 ± 9.4 cm2; p = 0.01) compared to the non-adherent group. When the
group was divided according to adherence to exercise and protein intake or non-adherence to both conditions, there was a
significant difference in TWL, FM, and VFM losses (p < 0.05). In contrast, no differences in SMM were found.
Conclusions Early exercise training accelerated visceral fat mass loss during the initial recovery period in patients after
bariatric surgery. Additionally, adherence to daily protein intake recommendations can increase total body weight and fat
mass loss.
Keywords Abdominal visceral fat· Bariatric surgery· Exercise· Patients’ adherence· Weight loss
Introduction
Bariatric surgery is an effective therapeutic strategy to
induce body mass loss and to improve metabolic profile in
obese patients [1]. Approximately ten percent of the initial
body mass is lost during the first month after surgery as a
result of the severe caloric restriction induced by procedure
[2]. Unfortunately, there is also a rapid fat-free mass (FFM)
loss during this period, which may go up to a third of the
excess weight loss (EWL) [3, 4].
Obesity also is associated with an excess of visceral,
subcutaneous, and ectopic fat and the evidence shows that
abdominal fat depots are strongly correlated with cardiomet-
abolic effects. Increased ectopic fat in and around the kidney
is associated with hypertension, albuminuria, and progres-
sion of chronic kidney disease (CKD) [5]. The relationship
between visceral fat and ectopic fat has been recently stud-
ied, showing a positive association between the accumula-
tion of visceral fat deposits and periorgan and intraorgan fat
(including skeletal muscle, liver, and renal sinus) [6].
The reduction of retroperitoneal adipose tissue volume
and the improvement of intraperitoneal adipose tissue qual-
ity were associated with an improved metabolic health status
in individuals with morbid obesity after bariatric surgery [7].
Key Points
• Those who adhered to exercise recommendations early after
bariatric surgery lost significantly more visceral fat than those
who did not.
• Combined adherence to exercise and protein intake increases
overall fat and weight loss.
• Sixty-six percent of patients adhered to the exercise
recommendations during the first month after bariatric surgery.
Extended author information available on the last page of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Early Exercise Through Telerehabilitation After Bariatric Surgery: Is It Feasible?
Article
Full-text available
  • Apr 2024
  • OBES SURG
Purpose The feasibility of early telerehabilitation after bariatric surgery is unknown. The objective of this study was to assess the feasibility and perception of engaging in the online exercise protocol in patients during the first month after bariatric surgery. Material and Methods A total of 67 patients, enrolled in a telerehabilitation program following bariatric surgery, completed a survey assessing their perception of the intensity, discomfort, and safety during exercise sessions. Results Forty percent of participants began exercising between 5 and 10 days after surgery. Seventy-one percent of patients did not experience discomfort during the first month of exercise, and those who reported discomfort mainly mentioned dizziness and abdominal pain. No significant differences were found in the presence of discomfort among different types of surgeries performed. There was a significant difference in the presence of discomfort between patients who started exercising before and after 15 days of surgery, with less discomfort reported in the group that started after 15 days. Ninety-eight percent of patients felt safe during online exercise sessions. Most participants perceived the intensity of the sessions as moderate. The most frequently mentioned benefits of exercise were increased energy, mood, and feeling more active. Conclusion Telerehabilitation conducted during the first month after bariatric surgery was feasible and well tolerated by patients, providing a safe alternative for those patients who face difficulties with in-person interventions. Graphical Abstract
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Dose–response effects of exercise and caloric restriction on visceral adiposity in overweight and obese adults: a systematic review and meta-analysis of randomised controlled trials
Article
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  • Jan 2023
Objective To determine and compare the dose–response effects of exercise and caloric restriction on visceral adipose tissue in overweight and obese adults, while controlling for the weekly energy deficit induced by the interventions. Methods PubMed, Embase, CINAHL and Web of Science were searched for randomised controlled trials comparing exercise or caloric restriction against eucaloric controls in overweight or obese adults. The primary outcome was the change in visceral fat measured by CT or MRI. Meta-analyses and meta-regressions were performed to determine the overall effect size (ES) and the dose–dependent relationship of exercise and caloric restriction on visceral fat. Heterogeneity, risk of bias and the certainty of evidence were also assessed. Results Forty randomised controlled trials involving 2190 participants were included. Overall, exercise (ES −0.28 (−0.37 to −0.19); p<0.001; I ² =25%) and caloric restriction (ES −0.53 (−0.71 to −0.35); p<0.001; I ² =33%) reduced visceral fat compared with the controls. Exercise demonstrated a dose–response effect of −0.15 ((−0.23 to −0.07); p<0.001) per 1000 calories deficit per week, whereas the effect of caloric restriction was not dose-dependent (ES 0.03 (−0.12 to 0.18); p=0.64). Most of the studies showed a moderate risk of bias. Conclusions These findings support the dose–dependent effects of exercise to reduce visceral fat in overweight and obese adults. Caloric restriction did not demonstrate a dose–response relationship, although this may be attributed to the smaller number of studies available for analysis, compared with exercise studies. PROSPERO registration number CRD42020210096.
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2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery
Article
Full-text available
  • Oct 2022
  • SURG OBES RELAT DIS
Major updates to 1991 National Institutes of Health guidelines for bariatric surgery •Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) ≥35 kg/m², regardless of presence, absence, or severity of co-morbidities. •MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m². •BMI thresholds should be adjusted in the Asian population such that a BMI ≥25 kg/m² suggests clinical obesity, and individuals with BMI ≥27.5 kg/m² should be offered MBS. •Long-term results of MBS consistently demonstrate safety and efficacy. •Appropriately selected children and adolescents should be considered for MBS.
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Is the Peri-Bariatric Surgery Exercise Program Effective in Adults with Obesity: a Systematic Review
Article
Full-text available
  • Feb 2022
  • OBES SURG
The number of people with obesity continues to increase. Bariatric surgery is the most effective treatment for severe obesity. However, this surgery also has disadvantages, such as an increased risk of excessive loss of fat-free mass, lean body mass, and muscle mass compared to other weight loss interventions. PubMed and Cochrane Library database including articles in English, Dutch, French, and German were used. From the 3609 retrieved references, 20 articles were selected. Compared with the control group, physical exercise improved body mass index (5 of 13 articles), weight loss (7 of 17 articles), functional capacity (2 of 5 articles), muscle strength (1 of 1 article), fat-free mass (3 of 5 articles), cardiorespiratory endurance (4 of 6 articles), and quality of life (2 of 4 articles) in obese patients undergoing BS. Current data is suggestive of positive effects of exercise on body mass index, weight loss, functional capacity, muscle strength, fat-free mass, cardiorespiratory endurance, and quality of life in obese patients undergoing bariatric surgery. However, our conclusions are limited because of the heterogeneity of programs and short studies. Further research is needed to determine the most effective physical exercise program in peri-bariatric surgery. Graphical abstract
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Nutrient and Fluid Requirements in Post-bariatric Patients Performing Physical Activity: A Systematic Review
Article
Full-text available
  • Dec 2021
  • NUTRITION
Background & Aims The evidence for the benefits of physical activity in post-bariatric patients is growing. Nevertheless, it remains unclear if nutritional regimens should be adapted to physical activity levels. This systematic review aimed to summarize current evidence regarding nutrient and fluid requirements in physically active post-bariatric patients. Methods We conducted this systematic review according to the PRISMA guidelines. We searched MEDLINE, Embase, and the Cochrane Library for studies assessing nutritional aspects in physically active post-bariatric patients. Data were extracted based on a predefined, standardized form, and assessed for risk of bias. Results Of 582 records, eight studies were included, mostly implementing general fitness programs (30-60 min/day, 3-4 times/week). There is no evidence for increased energy requirements in physically active post-bariatric patients. None of the studies determined energy, fat or carbohydrate requirements. Most studies focused on protein, recommending a minimum intake of 60 g/day to preserve/increase muscle mass (upper limit 1.5 g protein/kg ideal body weight/day). Higher protein intake (108 g/day, thereof 48 g whey protein) combined with physical activity increased muscle strength. The impact of physical activity on micronutrient requirements remains unstudied, while fluid requirements appear to be increased. Conclusion Our findings strengthen the importance of adequate protein intake in physically active post-bariatric patients. Nutrient reference values for physically active post-bariatric patients are not definable based on the current evidence. Consequently, clinicians should pay special attention to the monitoring of macro-/micronutrients and fluid balance, especially when post-bariatric patients engage in high levels of physical activity.
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Protein supplementation during an energy-restricted diet induces visceral fat loss and gut microbiota amino acid metabolism activation: a randomized trial
Article
Full-text available
  • Aug 2021
Interactions between diet and gut microbiota are critical regulators of energy metabolism. The effects of fibre intake have been deeply studied but little is known about the impact of proteins. Here, we investigated the effects of high protein supplementation (Investigational Product, IP) in a double blind, randomised placebo-controled intervention study (NCT01755104) where 107 participants received the IP or an isocaloric normoproteic comparator (CP) alongside a mild caloric restriction. Gut microbiota profiles were explored in a patient subset (n = 53) using shotgun metagenomic sequencing. Visceral fat decreased in both groups (IP group: − 20.8 ± 23.2 cm ² ; CP group: − 14.5 ± 24.3 cm ² ) with a greater reduction ( p < 0.05) with the IP supplementation in the Per Protocol population. Microbial diversity increased in individuals with a baseline low gene count ( p < 0.05). The decrease in weight, fat mass and visceral fat mass significantly correlated with the increase in microbial diversity ( p < 0.05). Protein supplementation had little effects on bacteria composition but major differences were seen at functional level. Protein supplementation stimulated bacterial amino acid metabolism (90% amino-acid synthesis functions enriched with IP versus 13% in CP group ( p < 0.01)). Protein supplementation alongside a mild energy restriction induces visceral fat mass loss and an activation of gut microbiota amino-acid metabolism. Clinical trial registration : NCT01755104 (24/12/2012). https://clinicaltrials.gov/ct2/show/record/NCT01755104?term=NCT01755104&draw=2&rank=1 .
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Interrelationships Among Accumulations of Intra- and Periorgan Fats, Visceral Fat, and Subcutaneous Fat
Article
  • Apr 2024
We aimed to clarify the relationship between intra- and periorgan fats, visceral fat, and subcutaneous fat. We used abdominal computed tomography to evaluate intra- and periorgan fat accumulations in the pancreas, liver, spleen, renal parenchyma, renal sinus, and skeletal muscle. The relationships between these fats, visceral fat, and subcutaneous fat were examined by using partial correlation and covariance analysis, adjusting for BMI. We found that visceral fat and all intra- and periorgan fat accumulations were positively correlated, whereas subcutaneous fat and accumulations of all intra- and periorgan fats and visceral fat were negatively correlated. Individuals with excessive visceral fat accumulation had significantly greater accumulations of fat in the pancreas, liver, renal sinus, and skeletal muscle than those without excessive visceral fat accumulation (P = 0.01, 0.006, 0.008, and 0.02, respectively). In conclusion, all intra- and periorgan fat accumulations show a positive correlation with visceral fat and a negative correlation with subcutaneous fat, independent of BMI. Article Highlights
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Changes in abdominal fat depots after bariatric surgery are associated with improved metabolic profile
Article
  • Dec 2022
Background and aims: Obesity associated with a change in the quantity and quality of fat depots. Using computed tomography (CT), we analyzed abdominal fat depots in patients with obesity after bariatric surgery according to their metabolic health status. Methods and results: We recruited 79 individuals with metabolically unhealthy obesity before bariatric surgery and compared them with age-sex matched healthy controls. The volume and fat attenuation index (FAI) of fat depots were measured using CT scans that were conducted prior to and a year after bariatric surgery. 'Metabolically healthy' was defined as having no hypertension, normal fasting glucose and a waist-to-hip ratio of <1.05 for men and <0.95 for women. Individuals who achieved a metabolic health status conversion (MHC) (n = 29, 37%)-from unhealthy to healthy-were younger (p < 0.001) as compared to individuals without MHC. Pre-surgery BMI and reduction of BMI did not differ between the two groups (p = 0.099, p = 0.5730). Bariatric surgery reduced the volume and increased the FAI of fat depots. Baseline lower abdominal periaortic adipose tissue (AT) volume (p = 0.014) and great percent reduction in renal sinus AT volume after surgery (p = 0.019) were associated with MHC after surgery. Increased intraperitoneal AT FAI (p = 0.031) was also associated with MHC. Conclusion: MHC was not associated with improvement in general obesity, based on indicators such as reduction of BMI after surgery. Weight reduction induced specific abdominal fat depot changes measured by CT are positively associated with MHC.
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Effect of aerobic exercise on waist circumference in adults with overweight or obesity: A systematic review and meta‐analysis
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  • Apr 2022
Excess visceral adiposity contributes to elevated cardiometabolic risk, and waist circumference is commonly used as a surrogate measure of visceral adipose tissue. Although regular aerobic exercise is known to improve abdominal obesity, its effect on waist circumference is unclear. A systematic review and meta‐analysis was performed to determine (1) the effect of aerobic exercise on waist circumference in adults with overweight or obesity; (2) the association between any change in waist circumference and change in visceral adipose tissue and/or bodyweight with aerobic exercise interventions; and (3) if reductions in waist circumference with exercise are moderated by clinical characteristics or components of aerobic exercise prescription. Twenty‐five randomized controlled trials (1686 participants) were included. Regular aerobic exercise significantly reduced waist circumference by 3.2 cm (95% confidence interval [CI] −3.86, −2.51, p ≤ 0.001) versus control. Change in waist circumference was associated with change in visceral adipose tissue (β = 4.02; 95% CI 1.37, 6.66, p = 0.004), and vigorous intensity produced superior reduction (−4.2 cm, 95% CI −4.99, −3.42, p < 0.0001) in waist circumference compared with moderate intensity (−2.50 cm, 95% CI −3.22, −1.79, p = 0.058). These findings suggest regular aerobic exercise results in modest reductions in waist circumference and associated visceral adipose tissue and that higher intensity exercise may offer superior benefit to moderate intensity.
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