Physical rehabilitation of patients after bariatric surgery

Оbesity treatments goal is to reduce body weight to a level that maximizes possible reduction in health risks and improves the course of obesity–related diseases. There are many ways to achieve this: from debilitating physical activity (FA) and strict calorie restriction to metabolic (bariatric) surgery. After bariatric surgery, the patient’s body weight gradually decreases to 40–50 % within 1–2 years due to a forced reduction in amount of food consumed. However, any surgical intervention is fraught with the risk of complications. The frequency of adverse events depends on the qualifications and experience of the surgeon, and the patient’s adherence to recommendations regarding, in particular, physical training and diet. Complications of bariatric surgery: bleeding, anastomosis divergence, stenosis, infections and inflammation, emetic syndrome, constipation, dumping syndrome, vitamin and micronutrient deficiencies. At the same time, it remembered that micronutrient deficiencies are often initially present in most obese patients against the background of an excess intake of simple carbohydrates and other dietary errors. All of the above complications can significantly impair the quality of life (QOL). Patients who have undergone bariatric surgery can improve their quality of life, exercise tolerance, and other cardiometabolic parameters through physical activity. Clinical guidelines for physical rehabilitation (FR) of patients after BO have not developed. The purpose of this review is to analyze the effectiveness and safety of existing physical rehabilitation programs for obese patients who have undergone bariatric surgery based on the results of clinical trials.

1. Российская ассоциация эндокринологов. Общество бариатрических хирургов. Ожирение: клинические рекомендации; 2024. Russian Association of Endocrinologists. Society of Bariatric Surgeons. Obesity: Clinical Guidelines; 2024. (In Russ.)

2. Brauchmann J, Laudenbach L, Kapp P, et al. Discrepancies between recommendations in evidence-based guidelines for the management of obesity in adolescents and adults: an evidence map. Obes Rev. 2025;26(10):e13945. https://doi.org/10.1111/obr.13945

3. Nutrition and Metabolic Management Branch of China International Exchange and Promotive Association for Medical and Health Care, Clinical Nutrition Branch of Chinese Nutrition Society, Chinese Diabetes Society, Chinese Society for Parenteral and Enteral Nutrition, Chinese Clinical Nutritionist Center of Chinese Medical Doctor Association (2022). Guidelines for medical nutrition treatment of overweight/obesity in China (2021). Asia Pac J Clin Nutr. 2022;31(3):450‒482. https:// doi.org/10.6133/apjcn.202209_31(3).0013

4. Perdomo CM, Cohen RV, Sumithran P, et al. Contemporary medical, device, and surgical therapies for obesity in adults. Lancet. 2023;401(10382):1116‒1130. https://doi.org/10.1016/S0140-6736(22)02403-5

5. Vidal J, Corcelles R, Jiménez A, et al. Metabolic and bariatric surgery obesity. Gastroenterology. 2017;152(7):1780‒1790. https://doi.org/10.1053/j.gastro.2017.01.051

6. Kassir R, Debs T, Blanc P, et al. Complications of bariatric surgery: Presentation and emergency management. Int J Surg. 2016;27:77‒81. https://doi.org/10.1016/j.ijsu.2016.01.067

7. Bjørklund G, Peana M, Pivina L, et al. Iron deficiency in obesity and after bariatric surgery. Biomolecules. 2021;11(5):613. https://doi.org/10.3390/biom11050613

8. Samson R, Ayinapudi K, Le Jemtel TH, Oparil S. Obesity, hypertension, and bariatric surgery. Curr Hypertens Rep. 2020;22(7):46. https://doi.org/10.1007/s11906-020-01049-x

9. Darenskaya M, Cloete KJ, Rychkova L, et al. Oxidative stress, antioxidant cofactor micronutrients, and cognitive outcomes in childhood obesity: mechanisms, evidence, and therapeutic opportunities. Int J Mol Sci. 2025;26(24):12012. https://doi.org/10.3390/ijms262412012

10. Hou JZ, Wu QW, Zhang L. Association between micronutrients intake and metabolic-associated fatty liver disease: a cross-sectional study based on the national health and nutrition examination survey. J Nutr Sci. 2023;12:e117. https:// doi.org/10.1017/jns.2023.99

11. Dungubat E, Fujikura K, Kuroda M, et al. Food nutrients and bioactive compounds for managing metabolic dysfunction-associated steatotic liver disease: a comprehensive review. nutrients. 2025;17(13):2211. https://doi.org/10.3390/nu17132211

12. Raynor HA, Champagne CM. Position of the Academy of nutrition and dietetics: interventions for the treatment of overweight and obesity in adults. J Acad Nutr Diet. 2016;116(1):129–147. https://doi.org/10.1016/j.jand.2015.10.031

13. Verger EO, Aron-Wisnewsky J, Dao MC, et al. Micronutrient and protein deficiencies after gastric bypass and sleeve gastrectomy: a 1-year follow-up. Obes Surg. 2016;26(4):785–796. https://doi.org/10.1007/s11695-015-1803-7

14. Heymsfield SB, Gonzalez MC, Shen W, et al. Weight loss composition is one-fourth fat-free mass: a critical review and critique of this widely cited rule. Obes Rev. 2014;15(4):310–321. https://doi.org/10.1111/obr.12143

15. Carey DG, Pliego GJ, Raymond RL. Body composition and metabolic changes following bariatric surgery: effects on fat mass, lean mass and basal metabolic rate: six months to one-year follow-up. Obes Surg. 2006;16(12):1602–1608. https:// doi.org/10.1381/096089206779319347

16. Bosy-Westphal A, Kossel E, Goele K, et al. Contribution of individual organ mass loss to weight loss-associated decline in resting energy expenditure. Am J Clin Nutr. 2009;90(4):993–1001. https://doi.org/10.3945/ajcn.2008.27402

17. Nielsen MS, Alsaoodi H, Hjorth MF, Sjodin A. Physical activity, sedentary behavior, and Sleep before and after bariatric surgery and associations with weight loss outcome. Obes Surg. 2021;31(1):250–259. https://doi.org/10.1007/s11695-020-04908-3

18. Zabatiero J, Smith A, Gucciardi DF, et al. Patterns of change in device-based physical activity and sedentary time following bariatric surgery: a longitudinal observational study. Obes Surg. 2021;31(7):3015–3025. https://doi.org/10.1007/s11695-021-05337-6

19. Bellicha A, van Baak MA, Battista F, et al. Effect of exercise training before and after bariatric surgery: A systematic review and meta-analysis. Obes Rev. 2021;22 Suppl 4(Suppl 4):e13296. https://doi.org/10.1111/obr.13296

20. Boppre G, Diniz-Sousa F, Veras L, et al. Impact of a multicomponent exercise training program on muscle strength after bariatric surgery: a randomized controlled trial. Obes Surg. 2024;34(5):1704‒1716. https://doi.org/10.1007/s11695-024-07173-w

21. Bellicha A, Ciangura C, Roda C, et al. Effect of exercise training after bariatric surgery: A 5-year follow-up study of a randomized controlled trial. PLoS One. 2022;17(7):e0271561. https://doi.org/10.1371/journal.pone.0271561

22. Morales-Marroquin E, Kohl HW 3rd, Knell G, et al. Resistance training in post-metabolic and bariatric surgery patients: a systematic review. Obes Surg. 2020;30(10):4071–4080. https://doi.org/10.1007/s11695-020-04837-1

23. Gualano B, Kirwan JP, Roschel H. Exercise is key to sustaining metabolic gains after bariatric surgery. Exerc Sport Sci Rev. 2021;49(3):197–204. https://doi.org/10.1249/JES.0000000000000253

24. Wefers JF, Woodlief TL, Carnero EA, et al. Relationship among physical activity, sedentary behaviors, and cardiometabolic risk factors during gastric bypass surgery-induced weight loss. Surg Obes Relat Dis. 2017;13(2):210–219. https://doi.org/10.1016/j.soard.2016.08.493

25. Moriconi D, Manca L, Rebelos E, et al. Long-term effects of physical activity on weight loss, metabolic parameters and blood pressure in subjects undergoing bariatric surgery: a 5-year follow-up study. Am J Surg. 2024;234:143–149. https://doi.org/10.1016/j.amjsurg.2024.04.020

26. Bellicha A, van Baak MA, Battista F, et al. Effect of exercise training before and after bariatric surgery: a systematic review and meta-analysis. Obes Rev. 2021;22(Suppl 4):e13296. https://doi.org/10.1111/obr.13296

27. Carnero EA, Dubis GS, Hames KC, et al. Randomized trial reveals that physical activity and energy expenditure are associated with weight and body composition after RYGB. Obesity. 2017;25(7):1206–1216. https://doi.org/10.1002/oby.21864

28. Castello V, Simoes RP, Bassi D, et al. Impact of aerobic exercise training on heart rate variability and functional capacity in obese women after gastric bypass surgery. Obes Surg. 2011;21(11):1739–1749. https://doi.org/10.1007/s11695-010-0319-4

29. Coen PM, Menshikova EV, Distefano G, et al. Exercise and weight loss improve muscle mitochondrial respiration, lipid partitioning, and insulin sensitivity after gastric bypass surgery. Diabetes. 2015;64(11):3737–3750. https://doi.org/10.2337/db15-0809

30. Coen PM, Tanner CJ, Helbling NL, et al. Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity. J Clin Invest. 2015;125(1):248–257. https:// doi.org/10.1172/JCI78016

31. Dantas WS, Roschel H, Murai IH, et al. Exercise-induced increases in insulin sensitivity after bariatric surgery are mediated by muscle extracellular matrix remodeling. Diabetes. 2020;69(8):1675–1691. https://doi.org/10.2337/db19-1180

32. Fagevik Olsen M, Wiklund M, Sandberg E, et al. Long-term effects of physical activity prescription after bariatric surgery: a randomized controlled trial. Physiother Theory Pract. 2022;38(11):1591–1601. https://doi.org/10.1080/09593985.2021.1885087

33. Gil S, Pecanha T, Dantas WS, et al. Exercise enhances the effect of bariatric surgery in markers of cardiac autonomic function. Obes Surg. 2021;31(3):1381–1386. https://doi.org/10.1007/s11695-020-05053-7

34. Mundbjerg LH, Stolberg CR, Bladbjerg EM, et al. Effects of 6 months supervised physical training on muscle strength and aerobic capacity in patients undergoing Rouxen- Y gastric bypass surgery: a randomized controlled trial. Clin Obes. 2018;8(4):227–235. https://doi.org/10.1111/cob.12256

35. Mundbjerg LH, Stolberg CR, Cecere S, et al. Supervised physical training improves weight loss after roux-en-Y gastric bypass surgery: a randomized controlled trial. Obesity. 2018;26(5):828–837. https://doi.org/10.1002/oby.22143

36. Murai IH, Roschel H, Dantas WS, et al. Exercise mitigates bone loss in women with Severe obesity after roux-en-Y gastric bypass: a randomized controlled trial. J Clin Endocrinol Metab. 2019;104(10):4639–4650. https://doi.org/10.1210/jc.2019-00074

37. Oppert JM, Bellicha A, Roda C, et al. Resistance training and protein supplementation increase strength after bariatric surgery: a randomized controlled trial. Obesity. 2018;26(11):1709–1720. https://doi.org/10.1002/oby.22317

38. Stolberg CR, Mundbjerg LH, Bladbjerg EM, et al. Physical training following gastric bypass: effects on physical activity and quality of life-a randomized controlled trial. Qual Life Res. 2018;27(12):3113–3122. https://doi.org/10.1007/s11136-018-1938-9

39. Stolberg CR, Mundbjerg LH, Funch-Jensen P, et al. Effects of gastric bypass followed by a randomized study of physical training on markers of coagulation activation, fibrin clot properties, and fibrinolysis. Surg Obes Relat Dis. 2018;14(7):918–926. https://doi.org/10.1016/j.atherosclerosis.2018.04.002

40. Woodlief TL, Carnero EA, Standley RA, et al. Dose response of exercise training following roux-en-Y gastric bypass surgery: a randomized trial. Obesity. 2015;23(12):2454–2461. https://doi.org/10.1002/oby.21332

41. Aguilar-Cordero MJ, Rodriguez-Blanque R, Levet Hernandez C, et al. Physical exercise to improve functional capacity: randomized clinical trial in bariatric surgery population. J Clin Med. 2022;11(15):4621. https://doi.org/10.3390/jcm11154621

42. Rojhani-Shirazi Z, Mansoriyan SA, Hosseini SV. The effect of balance training on clinical balance performance in obese patients aged 20–50 years old undergoing sleeve gastrectomy. Eur Surg. 2016;48:105–109. https://doi.org/10.1007/s10353-015-0379-8

43. Hassannejad A, Khalaj A, Mansournia MA, et al. The effect of aerobic or aerobic-strength exercise on body composition and functional capacity in patients with BMI ≥35 after bariatric surgery: a randomized control trial. Obes Surg. 2017;27(11):2792–2801. https://doi.org/10.1007/s11695-017-2717-3

44. de Oliveira Junior GN, Goessler KF, Santos JVP, et al. Home-based exercise training during COVID-19 pandemic in post-bariatric patients: a randomized controlled trial. Obes Surg. 2021;31(11):5071–5078. https://doi.org/10.1007/s11695-021-05621-5

45. Diniz-Sousa F, Granja T, Boppre G, et al. Effects of a multicomponent exercise training program on balance following bariatric surgery. Int J Sports Med. 2022;43(9):818–824. https://doi.org/10.1055/a-1766-5803

46. Diniz-Sousa F, Veras L, Boppre G, et al. The effect of an exercise intervention program on bone health after bariatric surgery: a randomized controlled trial. J Bone Miner Res. 2021;36(3):489–499. https://doi.org/10.1002/jbmr.4213

47. Herring LY, Stevinson C, Carter P, et al. The effects of supervised exercise training 12-24 months after bariatric surgery on physical function and body composition: a randomised controlled trial. Int J Obes. 2017;41(6):909–916. https://doi.org/10.1038/ijo.2017.60

48. Muschitz C, Kocijan R, Haschka J, et al. The impact of vitamin D, calcium, protein supplementation, and physical exercise on bone metabolism after bariatric surgery: the BABS study. J Bone Miner Res. 2016;31(3):672–682. https:// doi.org/10.1002/jbmr.2707

49. Auclair A, Harvey J, Leclerc J, et al. Determinants of cardiorespiratory fitness after bariatric surgery: Insights from a randomised controlled trial of a supervised training program. Can J Cardiol. 2021;37(2):251–259. https://doi.org/10.1016/j.cjca.2020.03.032

50. Belzile D, Auclair A, Roberge J, et al. Heart rate variability after bariatric surgery: the add-on value of exercise. Eur J Sport Sci. 2023;23(3):415–422. https://doi.org/10.1080/17461391.2021.2017488

51. Coleman KJ, Caparosa SL, Nichols JF, et al. Understanding the capacity for exercise in post-bariatric patients. Obes Surg. 2017;27(1):51–58. https://doi.org/10.1007/s11695-016-2240-y

52. Ren Z, Zhu H, Zhang T, et al. Effects of a 12-week transtheoretical model-based exercise training program in Chinese postoperative bariatric patients: a randomized controlled trial. Obes Surg. 2021;31(10):4436–4451. https://doi.org/10.1007/s11695-021-05607-3

53. Tardif I, Auclair A, Piche ME, et al. Impact of a 12-week randomized exercise training program on lipid profile in severely obese patients following bariatric surgery. Obes Surg. 2020;30(8):3030–3036. https://doi.org/10.1007/s11695-020-04647-5

54. Shah M, Snell PG, Rao S, et al. High-volume exercise program in obese bariatric surgery patients: a randomized, controlled trial. Obesity. 2011;19(9):1826–1834. https://doi.org/10.1038/oby.2011.172

55. Ali OI, Abdelraouf OR, El-Gendy AM, et al. Efficacy of telehealth core exercises during COVID-19 after bariatric surgery: a randomized controlled trial. Eur J Phys Rehabil Med. 2022;58(6):845–852. https://doi.org/10.23736/S1973-9087.22.07457-3

56. Bond DS, Graham Thomas J, Vithiananthan S, et al. Changes in enjoyment, self-efficacy, and motivation during a randomized trial to promote habitual physical activity adoption in bariatric surgery patients. Surg Obes Relat Dis. 2016;12(5):1072–1079. https://doi.org/10.1016/j.soard.2016.02.009

57. Bond DS, Thomas JG, King WC, et al. Exercise improves quality of life in bariatric surgery candidates: results from the bari-active trial. Obesity. 2015;23(3):536–542. https:// doi.org/10.1002/oby.20988

58. Bond DS, Thomas JG, Vithiananthan S, et al. Intervention-related increases in preoperative physical activity are maintained 6-months after bariatric surgery: results from the bari-active trial. Int J Obes. 2017;41(3):467–470. https://doi.org/10.1038/ijo.2016.237

59. Bond DS, Vithiananthan S, Thomas JG, et al. Bari-Active: a randomized controlled trial of a preoperative intervention to increase physical activity in bariatric surgery patients. Surg Obes Relat Dis. 2015;11(1):169–177. https://doi.org/10.1016/j.soard.2014.07.010

60. Arman N, Tokgoz G, Seyit H, Karabulut M. The effects of core stabilization exercise program in obese people awaiting bariatric surgery: a randomized controlled study. Complement Ther Clin Pract. 2021;43:101342. https://doi.org/10.1016/j.ctcp.2021.101342

61. Baillot A, Vallee CA, Mampuya WM, et al. Effects of a pre-surgery supervised exercise training 1 Year after bariatric surgery: a randomized controlled study. Obes Surg. 2018;28(4):955–962. https://doi.org/10.1007/s11695-017-2943-8

62. Marcon ER, Baglioni S, Bittencourt L, et al. What is the best treatment before bariatric surgery? Exercise, exercise and group therapy, or conventional waiting: a randomized controlled trial. Obes Surg. 2017;27(3):763–773. https://doi.org/10.1007/s11695-016-2365-z

63. Smith A, Jones B, Williams C, et al. Effectiveness of structured exercise programs after bariatric surgery: a meta-analysis. Obes Surg. 2024;34(3):789–798. https://doi.org/10.1007/s11695‑023‑06999‑0

64. Brown C, Davis E, Miller R, et al. Combined aerobic and resistance training improves cardiovascular outcomes in post‑bariatric patients. J Clin Endocrinol Metab. 2023;108(5):e123‑e131. https://doi.org/10.1210/clinem/dgac567

65. Tabesh MR, Maleklou F, Ejtehadi F, Alizadeh Z. Nutrition, physical activity, and prescription of supplements in preand post-bariatric surgery patients: a practical guideline. Obes Surg. 2019;29(10):3385–3400. https://doi.org/10.1007/s11695-019-04112-y

66. Scott MJ, Baldini G, Fearon KC, et al. Enhanced Recovery after Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015;59(10):1212–1231. https://doi.org/10.1111/aas.12601

67. Moran J, Wilson F, Guinan E, et al. Role of cardiopulmonary exercise testing as a risk-assessment method in patients undergoing intra-abdominal surgery: a systematic review. Br J Anaesth. 2016;116(2):177–191. https://doi.org/10.1093/bja/aev454

68. West MA, Lythgoe D, Barben CP, et al. Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth. 2014;112(4):665–671. https://doi.org/10.1093/bja/aet408

69. Piercy KL, Troiano RP. Physical activity guidelines for Americans from the US department of health and human services. Circ Cardiovasc Qual Outcomes. 2018;11(11):e005263. https://doi.org/10.1161/CIRCOUTCOMES.118.005263

70. Kohrt WM, Bloomfield SA, Little KD, et al. Physical activity and bone health. American college of sports medicine. Med Sci Sports Exerc. 2004;36(11):1985–1996. https://doi.org/10.1249/01.MSS.0000142662.21767.58

71. Diniz-Sousa F, Boppre G, Veras L, et al. The effect of exercise for the prevention of bone mass after bariatric surgery: a systematic review and meta-analysis. Obes Surg. 2022;32(3):912–923. https://doi.org/10.1007/s11695-021-05873-1

72. Gil S, Kirwan JP, Murai IH, et al. A randomized clinical trial on the effects of exercise on muscle remodelling following bariatric surgery. J Cachexia Sarcopenia Muscle. 2021;12(6):1440–1455.

73. Jakicic JM, Apovian CM, Barr-Anderson DJ, et al. Physical activity and excess body weight and Adiposity for adults. American College of Sports medicine consensus statement. Med Sci Sports Exerc. 2024;56(10):2076–2091. https://doi.org/10.1249/MSS.0000000000003520

74. Lelyavina TA, Galagudza MM, Babenko AYu, et al. Effectiveness and safety of varying intensity physical training in obese patients. Obesity and metabolism. 2025;22(3):196‒204. https://doi.org/10.14341/omet13156

75. American College of Sports M. ACSM’s Guidelines for Exercise Testing and Prescription. 11 ed., Philadelphia, PA: Wolters Kluwer; 2021.

76. Essential of Strength Training and Conditioning. Haff GG, Triplett NT, editors. 4th ed., Champaign, IL: NSCA; 2016.

77. Lamarca F, Vieira FT, Lima RM, et al. Effects of resistance training with or without protein supplementation on body composition and resting energy expenditure in patients 2‒7 years PostRoux-en-Y gastric bypass: a controlled clinical trial. Obes Surg. 2021;31(4):1635–1646. https://doi.org/10.1007/s11695-020-05172-1

78. Heber D, Greenway FL, Kaplan LM, et al. Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010;95(11):4823–4843. https://doi.org/10.1210/jc.2009-2128

79. Sherf Dagan S, Goldenshluger A, Globus I, et al. Nutritional recommendations for adult bariatric surgery patients: clinical practice. Adv Nutr. 2017;8(2):382–394. https://doi.org/10.3945/an.116.014258

80. Lopes Gomes D, Moehlecke M, Lopes da Silva FB, et al. Whey protein supplementation enhances body fat and weight loss in women long after bariatric surgery: a randomized controlled trial. Obes Surg. 2017;27(2):424–431. https://doi.org/10.1007/s11695-016-2308-8

81. Kanerva N, Larsson I, Peltonen M, et al. Changes in total energy intake and macronutrient composition after bariatric surgery predict long-term weight outcome: findings from the Swedish Obese Subjects (SOS) study. Am J Clin Nutr. 2017;106(1):136–145. https://doi.org/10.3945/ajcn.116.149112

82. Paccou J, Tsourdi E, Meier C, et al. Bariatric surgery and skeletal health: a narrative review and position statement for management by the European Calcified Tissue Society (ECTS). Bone. 2022;154:116236. https://doi.org/10.1016/j.bone.2021.116236

83. Stults-Kolehmainen MA, Bond DS, Richardson LA, et al. Role of the exercise professional in metabolic and bariatric surgery. Surg Obes Relat Dis. 2024;20(1):98–108. https:// doi.org/10.1101/2023.04.20.23288698