BARIATRIC NURSING AND SURGICAL PATIENT CARE

Volume 6, Number 2, 2011

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bar.2011.9971

Improved Exercise Behaviors Associated

with a Comprehensive Structured Exercise Program
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Following Bariatric Surgery

Sofija E. Zagarins, PhD,1 Nancy A. Allen, PhD, ANP,2 Sandra S. Skinner, RN, MA,3
Andrew J. Kemper, MD,4 and Garry Welch, PhD1

Background: Although regular exercise is a significant predictor of weight loss and weight loss maintenance,
bariatric surgery patients are mostly sedentary/ low active presurgery, and up to 44% of these patients do not
Bariatric Nursing and Surgical Patient Care 2011.6:85-90.

engage in regular exercise at 1 year postsurgery. Furthermore, of all postsurgical behavioral recommendations,
exercise is the most likely area of nonadherence. The goal of this study was to evaluate adherence to a structured,
postsurgical exercise program and to explore the preliminary efficacy of this program on trends in exercise
frequency, duration, and intensity.
Methods: Data on exercise behaviors during group exercise sessions and at home were collected from all 46
patients participating in a 12-week, structured, postsurgical exercise program. Linear regression was used to
determine whether exercise behaviors changed over time.
Results: The frequency and duration of at-home exercise increased from 3.3 (1.9) times per week for 37.4 (18.3)
min/session at week 1 to 4.3 (1.7) times per week for 50.8 (23.3) min/session at week 12 ( p < 0.01 for increase in
both frequency and duration). The level of exercise intensity during the weekly group exercise classes increased
from 3.5 (0.9) METs (metabolic equivalents; equivalent to a moderate walking pace) at week 1 to 6.3 (2.9) METs
(equivalent to a very brisk walking/slow jogging pace) at week 12 ( p < 0.01).
Conclusions: The significant improvements in exercise behaviors observed during this group exercise program
suggest that such programs are feasible, and may be effective in helping bariatric surgery patients meet the
postsurgical exercise recommendations associated with improved weight loss and overall health.

Introduction An important shift in nonsurgical obesity treatment re-

search is the focus on weight loss maintenance.6 This research

M orbid obesity (MO) affects 15 million adults in the

United States and is associated with serious comorbid-
ities, including cardiovascular, respiratory, metabolic, endo-
crine, and musculoskeletal disorders.1–3 Bariatric surgery is
currently the most effective treatment for MO and can reduce
or even eliminate these MO-related comorbidities.3 However,
recent reports have highlighted emerging problems with
weight plateau, weight loss variability, and weight regain at 18
to 24 months for a substantial number of bariatric surgery
patients.4,5 These issues threaten to undermine the impressive
preliminary improvements seen in MO-related comorbidities
following bariatric surgery, and emphasize the need for con-
tinuing postsurgical clinical support.
has shown that habitual daily exercise (defined as activity that
is planned, structured, repetitive, and purposeful with the aim
of improving aspects of physical fitness) is a significant pre-
dictor of weight loss and weight loss maintenance. Although
there is limited research related to exercise programs in MO
populations, these patients are mostly low active/sedentary
in terms of daily physical activity level presurgery.1,7,8 Fur-
thermore, up to 44% of bariatric surgery patients do not en-
gage in regular exercise at 1 year postsurgery, and of all
postsurgical behavioral recommendations (e.g., diet plan,
fluid intake, supplement use) exercise is the most likely area of
nonadherence.1,9 Given the problems of weight regain fol-
lowing surgery,4,5 bariatric surgical patients provide an

1
Department of Behavioral Medicine Research, Baystate Medical Center, Springfield, Massachusetts.
2
Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts.
3
Department of Wellness and Integrative Medicine, North Shore Medical Center, Salem, Massachusetts.
4
North Cardiovascular Associates, North Shore Medical Center, Salem, Massachusetts.

85
 86
excellent target group to apply medically safe exercise strat-
egies for weight loss and maintenance.
Although research on physical activity and exercise in
bariatric surgery patients is limited, several recent studies
based on patient self-report suggest that weight loss is im-
proved at higher levels of physical activity.1,10–12 While pa-
tients are typically advised by the surgical team at scheduled
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follow-up visits to increase physical activity to improve
postsurgical recovery and weight loss, a structured exercise
program is not standard practice in weight loss surgery clinics
in the United States.13 To date, no research has been published
to determine whether such programs would be feasible or if
they would be effective in increasing exercise behaviors in
postsurgical bariatric patients.
Methods
A descriptive study design based on a single patient cohort
was used to examine the study aims. Specifically, we aimed
to: (1) evaluate adherence to a structured, postsurgical exer-
cise program; and (2) explore the preliminary efficacy of this
Bariatric Nursing and Surgical Patient Care 2011.6:85-90.
program on trends in exercise frequency, duration, and in-
tensity in both group exercise sessions and exercise completed
at home (i.e., outside of the group sessions) over the course of
the 12-week program.
Study setting and population
North Shore Medical Center (NSMC) in Salem, MA, pro-
vides the only structured exercise program for bariatric sur-
gery patients that we are aware of nationally. NSMC has
operated this unique postsurgical program since 1999, and
has an annual pool of approximately 200 patients referred by
three bariatric surgeons. The exercise program is part of the
Comprehensive Surgical Weight Loss Program (CSWLP),
which also includes nutrition and stress management com-
ponents, and is run by a team comprised of bariatric surgeons,
exercise physiologists (EP), dieticians, bariatric nurses, and
administrative staff. All bariatric surgery patients at NSMC
are required to sign up for the CSWLP. Program costs not
covered by insurance are paid by the patient.
Patients begin attending CSWLP group exercise sessions at
approximately 1–2 months postsurgery and participate in
these weekly 2-h sessions for 12 weeks, such that sessions
include both newly enrolled and ‘‘ongoing’’ participants. Ex-
ercise sessions begin with a group warm-up, followed by in-
dividually tailored programs using cardio equipment (e.g.,
treadmills, recumbent exercise bicycles, elliptical machines)
during which patients are given an appropriate exercise goal
by the EPs (e.g., use the treadmill for 15 min at 3.5 mph on
setting 5, then move to the recumbent bike for 20 min at set-
ting 4). The cardio session is followed by a group weight-
lifting session led by an EP, which focuses on teaching
patients about appropriate exercises for all the major muscle
groups. The session ends with stretching.
All patients complete an exercise treadmill test (ETT) prior
to surgery, which the EPs use in tailoring a safe baseline ex-
ercise prescription for each patient. This exercise prescription
is based on the resting and maximal vital signs of pulse and
blood pressure, determined in the ETT, and includes a target
heart rate and a target exertion level for each patient to
achieve at their first group exercise session. This exercise
prescription is designed to educate patients about appropriate
ZAGARINS ET AL.
baseline exercise levels, and is used as a starting point for the
first group exercise session. EPs then encourage patients to
increase their exercise intensity, frequency, and duration over
the course of the 12-week program, as appropriate. The EPs
have found this to be a safe postsurgical strategy for these
bariatric patients.
In addition to the weekly group exercise sessions, all pa-
tients are also encouraged to participate in regular exercise
outside of the program. Patients are encouraged to apply
what they learn about appropriate exercise type, intensity,
and duration in the group classes to their at-home exercise
program. This at-home program is largely focused on regular
walking sessions, and patients are encouraged to use a pe-
dometer to track their progress.
Data collection and statistical analysis plan
Data on exercise frequency, duration, and intensity during
both group exercise sessions and exercise completed outside
of the group sessions were collected from all patients who had
participated in the CSWLP by March 23, 2010, and who had
bariatric surgery (i.e., laparoscopic adjustable gastric banding
[LAGB] or gastric bypass surgery [GBS]) between October 1,
2009, and February 28, 2010. Patients began the CSWLP at
different times. For the purposes of this analysis, patient data
were sorted by week in program rather than by calendar date;
therefore week 1 data represent each patient’s first day in the
program.
Data collected at group exercise sessions included demo-
graphic information, clinical information, and exercise-related
information. Data on exercise completed during the group
exercise sessions were collected by the EPs, and data on ex-
ercise completed outside of the group sessions were self-
reported by patients in weekly exercise logs provided by the
EPs. Data collected during the group sessions included type of
exercise, duration of each type of exercise, metabolic equiva-
lent (MET) level during exercise, and perceived exertion level
during exercise assessed using the Borg Scale. The Borg Scale
ranges from 6, representing no exertion at all, to 20, rep-
resenting maximal exertion.14 Self-reported data collected on
exercise completed outside of the group sessions included
number of exercise sessions per week, duration of exercise,
type of exercise, and average Borg level during exercise. Data
on exercise frequency, duration, METs, and Borg levels were
summarized using means and standard deviations (SD).
Linear regression was used to determine whether these ex-
ercise variables changed over time.
Pedometer use data were collected from patient exercise
logs for the period from February 9, 2010, through March 23,
2010. Among those using pedometers each week, means and
SDs were calculated for days per week of pedometer use and
pedometer steps per day. Linear regression was used to de-
termine whether pedometer use changed over time.
Results
For the period from October 1, 2009, through February 28,
2010, 59 patients had bariatric surgery at NSMC. Of these, 46
(LAGB: n ¼ 15; GBS: n ¼ 31) attended at least one weekly
CSWLP group exercise session by March 23, 2010. For the 46
patients included in this analysis, mean (SD) age at surgery
was 43.2 (12.2) years and 80.4% were female (Table 1). Mean
preoperative body mass index (BMI) was 44.7 (6.3) kg/m2,
 BARIATRIC EXERCISE PROGRAM 87

Table 1. Selected Characteristics of Study All 46 patients also reported the frequency and duration of
Participants at Baseline (n ¼ 46) exercise completed outside of the group exercise sessions. At
week 1, patients exercised an average of 3.3 (1.9) times per
Mean (SD) Range
week for 37.4 (18.3) min/session, and this increased to 4.3 (1.7)
Age at surgery (years) 43.2 (12.2) 22.8–62.5 times per week for 50.8 (23.3) min/session at week 12
Preoperative BMI 44.7 (6.3) 33.6–59.1 ( p < 0.01 for increase in both frequency and duration; Fig. 2a).
Percent excess weight 49.0 (7.0) 33.0–61.3 Perceived level of exertion also increased steadily, from a Borg
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prior to surgery level of 11.9 (1.4) at week 1 to 15.2 (1.7) by week 12 (r2 ¼ 0.21,
Female (n, %) 37 (80.4%) — p < 0.01; Fig. 2b). Mean pedometer steps per day increased
Type 2 diabetes at baseline (n, %) 11 (23.9%) — significantly across the 12-week program, from a low of 7,600
Hypertension at baseline (n, %) 20 (43.5%) — steps/day at week 3 to a high of 12,750 steps/day at week 11
Hyperlipidemia at baseline (n, %) 23 (50.0%) — (r2 ¼ 0.14, p < 0.01; Fig. 2c).
Type of surgery
Gastric bypass surgery (n, %) 31 (67.5%) — Discussion
Laparoscopic adjustable gastric 15 (32.5%) —
banding (n, %) This analysis of a structured, postoperative exercise pro-
gram for bariatric surgery patients showed that exercise be-
SD, standard deviation; BMI, body mass index. haviors improved significantly over the course of the 12-week
CSWLP. Specifically, the frequency, duration, and intensity of
which corresponded to a percent excess weight of 49.0% exercise increased, as did perceived exertion during exercise
(7.0%). Percent excess weight loss (%EWL) from surgery to the and pedometer steps per day. Enrollment among patients
Bariatric Nursing and Surgical Patient Care 2011.6:85-90.

first group session was 19.7% (8.3%).
Of the 46 who began the program, six (13%) dropped out
(defined as continued absence from group exercise sessions
for 4 weeks), 13 completed the 12-week program, and 27
were still enrolled in the program as of March 23, 2010 (Table
2). For the 13 patients who completed the 12-week program,
%EWL increased to 38.8% (12.0%) by the final group session.
GBS patients (n ¼ 10) had a larger %EWL at 12 weeks com-
pared to LAGB patients (n ¼ 3), 43.0% and 24.9% respectively.
Using the Kruskal–Wallis test, this difference was found to be
statistically significant ( p ¼ 0.03).
At the weekly group exercise class sessions, the average
duration of exercise increased from 33.7 (8.8) min to 42.9 (7.4)
min (r2 ¼ 0.08, p < 0.01; Fig. 1a). Level of exercise intensity
increased from 3.5 (0.9) METs (equivalent to a moderate
walking pace) at week 1 to 6.3 (2.9) METs (equivalent to a
very brisk walking/slow jogging pace) at week 12 (r2 ¼ 0.20,
p < 0.01; Fig. 1b), and perceived level of exertion measured
using the Borg Scale increased from level 12.0 (1.4) (defined
as ‘‘fairly light’’ to ‘‘somewhat hard’’) at week 1 to level 14.3
(1.7) (defined as ‘‘hard’’) at week 12 (r2 ¼ 0.14, p < 0.01;
Fig. 1c).
eligible for the CSWLP was high (78%) and the dropout rate
during our data collection period among patients who began
the program was low (13%), indicating good adherence to the
program. These results highlight the feasibility of a structured
exercise program following bariatric surgery.
Although nonstructured physical activity has been shown
to improve postsurgical weight loss in bariatric surgery pa-
tients,1,10–12 the CSWLP at NSMC is the only structured,
postsurgical exercise program of its kind that we are aware of
nationally. While there was no comparison group for this
analysis, the significant improvements in exercise behaviors
observed over the course of this program suggest that such
programs may be effective in helping patients meet the ex-
ercise goals set forward in weight loss guidelines. The U.S.
Department of Health and Human Services recommends 150
to 300 min of moderate, medically appropriate exercise per
week for adults,15 a level achieved by all patients in the
present analysis. By comparison, our previous 2-year follow-
up study of bariatric surgery patients found only that 51.4% of
patients self-reported exercising to this guideline.1
While we were unable to compare directly weight loss in
CSWLP participants to a control group, %EWL in CSWLP

Table 2. Enrollment and Patient Characteristics by Week in Program

Number of Type of surgery ¼ gastric Mean (SD) age Mean (SD) percent excess Mean (SD) percent excess
patients enrolled bypass (n, %) at surgery weight prior to surgery weight lost since surgery

Week 1 46 31 (67.4%) 43.2 (12.2) 49.0 (7.0) 19.7 (7.0)

Week 2 41 27 (65.9%) 43.1 (12.2) 49.0 (6.5) 22.5 (8.9)
Week 3 35 23 (65.7%) 45.5 (11.4) 48.6 (6.8) 25.0 (10.2)
Week 4 29 21 (72.4%) 45.4 (11.9) 48.9 (6.6) 28.2 (11.0)
Week 5 28 20 (71.4%) 44.9 (11.8) 48.6 (6.5) 29.8 (11.5)
Week 6 23 17 (73.9%) 47.6 (10.6) 48.3 (6.3) 31.2 (10.7)
Week 7 20 15 (75.0%) 46.6 (10.9) 48.6 (6.5) 31.7 (9.4)
Week 8 20 15 (75.0%) 46.6 (10.9) 48.6 (6.5) 33.8 (9.8)
Week 9 17 13 (76.5%) 47.4 (10.3) 48.2 (6.7) 34.8 (9.8)
Week 10 15 11 (73.3%) 46.6 (10.4) 49.4 (6.1) 35.2 (10.2)
Week 11 13 10 (76.9%) 45.2 (10.5) 49.8 (6.5) 37.0 (11.4)
Week 12 13 10 (76.9%) 45.2 (10.5) 49.8 (6.5) 38.8 (12.0)
 88 ZAGARINS ET AL.

a 55

Duration of Exercise (Min.)

2
r = 0.08
50
p ≥ 0.01
45
40
35
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30
25
20
0 2 4 6 8 10 12
Week in Program

b 10
Exercise Intensity (METs)

8
2
r = 0.20
6 p ≥ 0.01

4
Bariatric Nursing and Surgical Patient Care 2011.6:85-90.

0
0 2 4 6 8 10 12
Week in Program

c 17
Perceived Level of Exertion

16
2
r = 0.14
15 p ≥0.01
(Borg)

14

13

12
11

10
0 2 4 6 8 10 12
Week in Program

FIG. 1. Trends for exercise completed during group exercise sessions: (a) mean (SD) duration in minutes; (b) mean (SD) intensity,
calculated in metabolic equivalents; (c) mean (SD) perceived level of exertion, based on self-report using the Borg Scale (range from 6
[no exertion at all] to 20 [maximal exertion]). Based on 46 participants contributing week 1 data, of whom 6 dropped out and 13
completed the program before the end of the data collection period (November 1, 2009–March 23, 2010). SD, standard deviation.

participants was high relative to national averages. Nation-
ally, GBS patients lose an average of 25% to 40% of their excess
weight by 3 to 6 months,16 while GBS patients in the CSWLP
lost an average of 43% of their excess weight by the end of the
program, which corresponds to 4 to 5 months postsurgery.
Limitations
The current analysis is based on a comprehensive post-
surgical program, which includes nutrition and stress man-
agement components. Thus it is possible that other aspects of
the program, and not just the exercise component, contributed
to our positive results. Conversely, it is also possible that these
nonexercise components of the CSWLP contributed to patient
dropout and/or reduced compliance. Of these, the first sce-
nario seems more likely given that improved exercise be-
haviors may encourage good nutritional choices and vice
versa.17
Data on exercise completed outside of the group sessions
were self-reported by patients, and as such may be less ac-
curate than data collected by the EPs during the group ses-
sions. However, patients were given weekly exercise
logbooks to use for tracking their at-home exercise, and were
shown how to complete the logbooks by the EPs. In addition,
trends in self-reported at-home exercise intensity and dura-
tion were similar to those measured by the EPs during the
group sessions, suggesting that patients were reporting the
information accurately.
Despite the small sample size at week 12 (n ¼ 13), we were
able to observe significant trends in exercise behaviors over
 BARIATRIC EXERCISE PROGRAM 89

Frequency of At-Home Exercise

7

6
r2 = 0.04

Sessions per Week

5 p ≥ 0.01
4
3
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2
1

0
0 2 4 6 8 10 12
Week in Program

b 17
Perceived Level of Exertion

16 r2 = 0.21
p ≥ 0.01
15
(Borg)

14
Bariatric Nursing and Surgical Patient Care 2011.6:85-90.

13
12
11
10
0 2 4 6 8 10 12
Week in Program

c 17000
15000
r2 = 0.14
Steps per Day

13000 p ≥ 0.01
11000
9000
7000
5000
3000
0 2 4 6 8 10 12

Week in Program

FIG. 2. Trends for exercise completed during at-home exercise sessions: (a) mean (SD) frequency of at-home exercise
sessions per week; (b) mean (SD) perceived level of exertion, based on self-report using the Borg Scale (range from 6 [no
exertion at all] to 20 [maximal exertion]); (c) mean (SD) steps per day among patients using pedometers. Based on 46
participants contributing week 1 data, of whom 6 dropped out and 13 completed the program before the end of the data
collection period (November 1, 2009–March 23, 2010).

the 12-week period. However, it is possible that the 13 pa-
tients who completed the program during our data collection
period differed from general CSWLP patient population, and
that a larger sample would reveal a more accurate picture of
exercise trends. Repeating this analysis in a larger population
would be useful in determining the extent to which the ob-
served results will generalize to other populations.
Conclusion
Changing lifelong sedentary behavioral patterns is difficult
and it is unknown whether the short-term exercise improve-
ments shown in this study will be maintained over time. Up to
44% of bariatric surgery patients do not engage in regular
exercise at one year post-surgery, and of all behavioral rec-
ommendations exercise is the most likely area of non-
adherence.1,9 A recent study by Bond et al. of patients
successfully maintaining weight loss found that patients who
lost weight via surgical methods reported less exercise and
dietary restraint than those who lost weight using non-surgical
methods.18 This Bond et al. study supports our current findings
that morbidly obese patients can successfully improve exercise
behaviors, but also suggests that bariatric surgery patients may
focus on the surgical control of hunger and food intake to
achieve weight loss and may not be realizing their weight loss
potential due to their lack of behavioral changes. Thus, a
structured exercise program may be of great benefit in helping
post-surgical patients achieve greater weight loss.
 90
There are many theories and models of behavior change,
such as Social Cognitive theory and Prochaska’s Trans-
theoretical Model,19,20 that have improved our understanding
of how individuals change behaviors. However, we currently
lack behavioral, theory-based exercise interventions for bar-
iatric surgery patients. In obese patients, effective behavioral
interventions have included self-monitoring, reducing eating
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cues, responding to social pressures, pre-planning and relapse
prevention techniques.21 The intervention examined in this
observational study applied these strategies, although we did
not formally assess the behavioral mechanisms used. Further
study is needed to clarify the nature and effectiveness of these
behavioral strategies over time.
This study examined the feasibility and effectiveness of a
structured post-operative group exercise program for bar-
iatric surgery patients and showed that participants signifi-
cantly increased exercise frequency, duration, and intensity
during the 12-week program. Novel strategies to improve
weight loss and medical outcomes for bariatric surgery pa-
tients are needed to tackle weight variability, weight plateaus,
and weight regain. The positive findings reported here sug-
Bariatric Nursing and Surgical Patient Care 2011.6:85-90.
gest that post-surgical exercise programs are feasible and are
effective in improving exercise behaviors, at least in the short
term, and support the need for a systematic program of clin-
ical research in this area.
Acknowledgments
We would like to thank the CSWLP staff for sharing their
time and expertise, and especially Jo-Anne Gibley, CPT, for
her assistance with data collection. The Comprehensive Sur-
gical Weight Loss Program at North Shore Medical Center is
funded in part by the Norman H. Read Charitable Trust.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Sofija E. Zagarins, PhD
Department of Behavioral Medicine Research
Baystate Medical Center
140 High Street, Room 298
Springfield, MA 01005
E-mail: Zagarins@gmail.com