Exercise and Bariatric Surgery

An Effective Therapeutic Strategy

Paul M. Coen; Elvis A. Carnero; Bret H. Goodpaster


Exerc Sport Sci Rev. 2018;46(4):262-270. 

In This Article

Abstract and Introduction


The long-term efficacy of bariatric surgery is not entirely clear, and weight regain and diabetes relapse are problems for some patients. Exercise is a feasible and clinically effective adjunct therapy for bariatric surgery patients. We hypothesize that exercise is also a critical factor for long-term weight loss maintenance and lasting remission of type 2 diabetes.


Severe obesity is defined as a body mass index (BMI) of ≥40 kg·m−2 and is a serious and prevalent health issue in many western countries, including the United States.[1] Obesity is now classified as a disease by the American Medical Association[2] and can cause many common adverse health outcomes including type 2 diabetes (T2D), cancer, arthritis, hypertension, and cardiovascular diseases.

Bariatric surgery is a generally safe and effective treatment option for obesity and encompasses a number of different procedures.[3] The most commonly performed bariatric surgery procedures in the United States, sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), result in dramatic weight loss, improvements in peripheral tissue insulin sensitivity, and diabetes remission in a large percentage of patients. A structured exercise program is a feasible and effective adjunct therapy for bariatric surgery patients that elicits additional cardiometabolic benefits compared with those experienced with bariatric surgery–induced weight loss alone.[4] Structured exercise increases total daily energy expenditure (TDEE) and improves skeletal muscle mitochondrial energetics, fat oxidation, and insulin sensitivity. It is not clear, however, whether exercise or physical activity (PA) can overcome the "metabolic adaptation" or decreased energy expenditure that occurs with surgery-induced weight loss and have an impact on overall daily energy balance. In recent years, the advent of technology that permits quantitative and comprehensive assessment of nonexercise PA (NEPA) and sedentary behavior underscores the importance of these behaviors in energy balance, weight regulation, and the development or worsening of obesity. These behaviors also likely contribute to outcomes after bariatric surgery.

In this review, we discuss our thesis that exercise or increases in PA can be effective as an adjunct therapy for bariatric surgery patients (Figure). This is a thesis that still needs to be rigorously tested, particularly in the context of long-term outcomes. We start by identifying some of the shortcomings of the surgical options for obesity treatment, including weight regain and diabetes relapse, and suggest that exercise improves energy balance, a critical factor for long-term surgery-induced weight loss maintenance, and contributes to lasting remission of T2D by improving and maintaining peripheral tissue insulin sensitivity. We draw on evidence from exercise and diet-induced weight loss studies to support our thesis. Finally, we outline the areas that future studies should focus on to generate the next level of evidence that will inform contemporary exercise guidelines for this rapidly growing patient population.


Potential mechanisms by which exercise can impart additional benefit in metabolic health for bariatric surgery patients who experience suboptimal weight loss and weight regain.