Journal of

Clinical Medicine

Systematic Review
Effects of Supervised Physical Exercise as Prehabilitation on
Body Composition, Functional Capacity and Quality of Life in
Bariatric Surgery Candidates: A Systematic Review and
Meta-Analysis
Andrea Herrera-Santelices 1,2 , Graciela Argüello-Florencio 3 , Greice Westphal 4 , Nelson Nardo Junior 4
and Antonio Roberto Zamunér 5, *

1 Facultad de Ciencias de la Salud, Universidad Católica de Maule, Talca 3480112, Chile

2 Servicio de Medicina Física y Rehabilitación, Hospital San Juan de Dios, Curicó 3343005, Chile
3 Department of Health Sciences, Nutrition and Dietetics Career, Faculty of Medicine, Pontificia Universidad
Católica de Chile, Santiago 8331150, Chile
4 Multidisciplinary Center of Obesity Studies, Department of Physical Education, Sate University of Maringa,
Maringá 87020-900, Brazil
5 Laboratory of Clinical Research in Kinesiology, Department of Kinesiology, Universidad Católica del Maule,
Talca 3480112, Chile
* Correspondence: beto.zam@gmail.com; Tel.: +56-71-2203100

Abstract: Background: Prehabilitation is a strategy used aiming to reduce the risk factors and
complications of surgery procedures, but there is no consensus on the effectiveness of supervised
physical exercise and its optimal prescription during this phase. Objectives: To determine the effects
Citation: Herrera-Santelices, A.; of exercise prehabilitation on body composition, functional capacity and quality of life in candidates
Argüello-Florencio, G.; Westphal, G.;
for bariatric surgery. Search methods: A search was conducted in PubMed, Web of Science, SciELO,
Nardo Junior, N.; Zamunér, A.R.
Scopus, MEDLINE and CINAHL. Selection criteria: Only randomized clinical trials that examined
Effects of Supervised Physical
the effectiveness of supervised physical exercise were included. The main outcomes were body
Exercise as Prehabilitation on Body
composition, functional capacity, quality of life and surgical outcomes. Data collection and analysis:
Composition, Functional Capacity
and Quality of Life in Bariatric
Two researchers independently selected the literature, extracted the data and evaluated the risk of
Surgery Candidates: A Systematic bias. A third researcher was consulted when a consensus was not reached. The risk of bias was
Review and Meta-Analysis. J. Clin. assessed by the tool recommended by the Cochrane Collaboration, the quality of the evidence by
Med. 2022, 11, 5091. https:// GRADE, and to analyze the effects of prehabilitation on the primary objectives, RevMan software,
doi.org/10.3390/jcm11175091 version 5.3 was used. Main results: The search resulted in 4550 articles, of which 22 met the eligibility
criteria, leaving 5 articles selected for this review. One article was assessed as a high bias risk and
Academic Editor: Gregory Hand
four as an uncertain risk, which included 139 candidates for bariatric surgery. Most of the studies
Received: 22 July 2022 evaluated the body composition, functional capacity and quality of life; none reported surgical
Accepted: 26 August 2022
outcomes. Conclusions: Supervised physical exercise has positive effects on the body composition,
Published: 30 August 2022
functional capacity and quality of life; there was no evidence for surgical outcomes, which opens up
Publisher’s Note: MDPI stays neutral a field of study for future research of this population.
with regard to jurisdictional claims in
published maps and institutional affil- Keywords: prehabilitation; bariatric surgery; obesity; physical exercise; quality of life
iations.

1. Introduction
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
Obesity is a chronic disease that is progressive, recurrent and creates health problems,
This article is an open access article
depending on the topographical location of excessive fat deposits. The most common health
distributed under the terms and problems are metabolic syndrome, high blood pressure, sarcopenia, osteopenia, diabetes
conditions of the Creative Commons mellitus, obstructive sleep apnea syndrome, dyslipidemia, depression and anxiety disorder,
Attribution (CC BY) license (https:// among others [1]. Therefore, several treatment pharmacological, non-pharmacological and
creativecommons.org/licenses/by/ surgical strategies have been proposed [2]. In this sense, bariatric surgery (BS) has proven
4.0/).

J. Clin. Med. 2022, 11, 5091. https://doi.org/10.3390/jcm11175091 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2022, 11, 5091 2 of 15

to be effective in solving comorbidities and promoting long-term weight loss in people

with obesity [3].
When a patient undergoes major abdominal surgery, such as BS, evidence suggests
that the proper preparation decreases the risks associated with the surgical procedure and
promotes a recovery that includes a higher pain tolerance, fewer hospital stays, less need
for rehospitalization and less surgical complications in the short and long term (e.g., venous
thrombosis, surgical wound dehiscence, bowel obstruction and adhesions development,
among others) [4–6].
Enhanced Recovery After Surgery (ERAS) is the current protocol used by different
surgical specialties to promote post-op recovery [7]. Regarding BS, the ERAS protocol
recommends several procedures and lifestyle changes, including diet control and the use
of some specific pharmacological prescription [7]. In addition, patients are encouraged
to participate in a preoperative weight loss program [6]. In that regard, it is well-known
that exercise has multiple benefits for a person’s physical and mental health, especially for
those with obesity. Exercise has been used as one of the main strategies for weight control
and in the treatment of different associated comorbidities, contributing to glycemic control;
lowering resting blood pressure and improving body composition, cardiorespiratory fitness,
sleep quality and quality of life [8,9]. Therefore, regular physical exercise could have an
important role in wight loss programs during prehabilitation for BS. However, despite
some randomized controlled trials (RCTs) having addressed this subject [10–12], there is
currently no clarity regarding its effectiveness on surgical outcomes (e.g., hospitalization
days, post-op pain tolerance, short- and long-term complications, rehospitalization, etc.);
mortality and other indices to support its recommendation in the ERAS protocol for BS [13].
Therefore, the objective of this systematic review is to determine the effect of prehabil-
itation on the body composition, functional capacity, quality of life and surgical outcomes
in patients who are candidates for BS.

2. Materials and Methods

The protocol for this systematic review was registered on PROSPERO; the registered
number is: CRD42021261474 [14]. This systematic review was conducted in accordance
with the PRISMA guidelines.

2.1. Search Plan and Literature Selection

The articles were searched in the following electronic databases: PubMed, Web of
Science, SciELO, Scopus, MEDLINE and CINAHL between 1 and 31 July 2021 without
restrictions of language or publication date. The descriptors used were: “Prehabilitation”,
“Physical Exercise”, “Body Composition”, “Functional Capacity”, “Quality of Life”, “Surgi-
cal Outcomes” and “Bariatric Surgery”; for the combinations of these, the Boolean operators
“AND” and/or “OR” were used. All studies were exported to the 5.4 version of StArt (State
of the Art through Systematic Review) software (developed by the Federal University of
São Carlos).

2.2. Types of Participants/Population

Inclusion criteria
Eighteen-year-old adults or older, both sexes and candidates for a first bariatric surgery
who were included in a prehabilitation program were included.
Exclusion criteria
Candidates for a second BS or reconversion surgery were excluded.

2.3. Types of Intervention/Exposition

For this review were considered randomized controlled clinical trials that applied
supervised physical exercise programs described as aerobic exercise training, resistance
exercise training or included both, with a duration of at least one week and performed
before bariatric surgery.
J. Clin. Med. 2022, 11, 5091 3 of 15

2.4. Types of Comparator/Control

The control was considered as a group receiving no intervention or only the stan-
dard care, defined as advice, counseling, brochures or leaflets on various health topics or
educational intervention of any kind.

2.5. Types of Outcome/Results Measurements

The studies were included if they reported the effect of the intervention on one or
more of the following outcomes: (1) Body composition: evaluated through dual-energy
x-energy absorptiometry or bioelectrical impedance; (2) Functional capacity: evaluated
through a functional test, for example, the six-minute walk test (6MWT), the direct or
indirect maximum rate of oxygen consumption (VO2 max), the sitting to standing test
or the step test among others; (3) Quality of life: evaluated through any quality of life
questionnaire and (4) Surgical outcomes such as the number of hospital stay days, the need
for rehospitalization within 30 days and post-op complications at 30 days were initially
considered. However, they were disregarded, since these outcomes were not reported by
any of the included studies.

2.6. Studies Selection

Two researchers (AH and GA) examined, independently, the studies that were identi-
fied by the search strategy using the 5.4 version of the StArt software. They were firstly
identified by reading the title and the abstract. In order to be selected, the abstracts had to
clearly identify the studies’ design, population, intervention and outcome measurements,
as previously described. In the event of a disagreement, a third researcher (GW) was
consulted who determined whether the article was included or not. Then, both researchers
moved on to reading the entirety of the potentially eligible articles and examined their
eligibility according to the inclusion criteria. Again, if there was a disagreement, a third
researcher was consulted. Conference reports and letters to the editor were excluded.

2.7. Data Extraction

After selecting the studies, two researchers (AH and GA) independently extracted the
data according to a “standard data extraction form” created by two researchers from the
team (AZ and AH). In the event of a disagreement between the reviewers, the data was
subjected to consensus or arbitration by a third reviewer (GW). Both reviewers conducted
a pilot test of data extraction using the standard data extraction form on two random-
ized controlled clinical trials that were related to exercise and its effect on cardiovascular
risk factors.

2.8. Risk of Bias Assessment

The studies’ risk of bias was independently evaluated by two researchers (AH and
GA) through the “Cochrane Risk of Bias Tool”, with 6 bias domains: selection, realization,
detection, attrition, report and others. Each domain is qualified as a high, low or uncertain
risk of bias (https://www.bmj.com/content/343/bmj.d5928, accessed on 25 October 2021).
Punctuation disagreements were discussed between them until a consensus was reached;
in case there was no agreement, a third researcher (GW) was consulted.

2.9. Evaluation of the Quality of Scientific Evidence

The quality of evidence in the studies was evaluated under GRADE (Grading of Rec-
ommendations Assessment, Development and Evaluation) criteria, including the study’s
limitations, the consistency of the effect, the inaccuracy, the evidence, and the publication
bias. The webpage www.gradepro.org was used.

2.10. Statistical Analysis

A meta-analysis was carried out using Review Manager software (RevMan, ver-
sion 5.3). Continuous outcomes were meta-analyzed using a random effects model and
J. Clin. Med. 2022, 11, 5091 4 of 15

standard mean differences (SMDs). Heterogeneity was quantified by the I-squared (I2 ) test
and classified as low: I2 < 25%, moderate: I2 = 25.1–50% and high: I2 > 50.1%.

3. Results
3.1. Article Selection
Figure 1 shows the flow chart pertaining to the identification of the studies and the
selection process of these. The results from searching the database were 4550 articles, of
which 626 were extracted while screening, because they were duplicates. Thus, 3924 were
analyzed by reading the title and its abstract, excluding 3902; then, 22 met the eligibility
criteria, 17 were excluded when the entire article was read and, finally, 5 studies were
included in this review.

Figure 1. Article identification PRISMA flow chart.

3.2. Articles’ Descriptions

Table 1 shows, in detail, the description of each article. The five articles selected for
review and meta-analysis were published between 2010 and 2021 in English; four of them
were performed on the American continent [11,15–17] and one in Europe [18].
J. Clin. Med. 2022, 11, 5091 5 of 15

Table 1. Description of each article.

[18] Arman et al. (2021)

Randomization Software Stratified by Sex and Age Was Used.
21 participants: 1 man—20 women.
Institution: Rehabilitation and Physical Therapy Department, Health Sciences Department,
Istanbul University-Cerrahpasa.
Country: Turkey.
Participants
Inclusion criteria: candidates to a BS, 18 years or older, both sexes.
Exclusion criteria: participants with comorbidities that prevent their participation in the
prehabilitation program like the existence of acute pain, cardiac pain or a previous dolor heart
attack, cardiac failure, diabetes, or uncompensated hypertension.
Program of the institution:
1. Warm-up (10–15 min): walk was performed on a treadmill; heart rate was monitored with a
pulse oximeter and as a goal it was set at 50 to 60 heartbeats.
2. Load (30–45 min): exercises for core stabilization were progressively performed in supine
position, long sitting position, knee position, crawling position, foot over one leg position and
sitting on a ball as exercise. Involved a combination of strengthening, resistance, and balance
exercises, along with breathing. Exercises for each main muscle group were performed during 2
Intervention cycles of 7 and 10 repetitions at a moderate intensity of 50% of maximum repetition. As sessions
progressed the number and intensity of exercises were gradually increased.
3. Cool down (10 min): stretching large muscle groups like hamstrings, hip flexors, shoulder
muscles, etc.
Total days of training: 16.
Duration of intervention: 8 weeks.
Frequency per week: 2 times.
Load adjustment: not detailed in the text.
1. Body composition: BMI, fat mass in kg, fat mass in %, free fat mass in kg.
(Bioelectrical impedance analysis).
2. Functional capacity: 6MWT, chair stand test, postural stability test, abdominal strength, core
Outcome measurements
flexor strength, modified push up test.
3. Quality of life: OSQOL.
4. Surgical objectives: not studied in the research.
Global risk bias Uncertain.
[11] Baillot et al. (2016)
Randomization Used software stratified by sex and maximum aerobic capacity (> o ≤ 7 MET).
29 participants: 7 men—22 women.
Institution: Centre hospitalier universitaire de Sherbrooke (CHUS), Quebec.
Country: Canada.
Inclusion criteria: candidates to BS, 18 years old or older, both sexes.
Participants
Exclusion criteria: participants with comorbidities that prevent their participation in the
prehabilitation program like a medical contraindication to practice physical activity, functional
limitations that do not allow them to perform the 6MWT, not understanding the French language,
or decompensated neuro-psychiatric pathology.
Gym program:
1. Warm-up (10 min).
2. Aerobic phase: 30 min of exercise (treadmill, walking circuit, arm ergometer, elliptical machine)
3. Resistance phase: 20 to 30 min.
4. Cool down: 10 min.
Total days of training: 24.
Intervention
Intervention duration: 12 weeks.
Frequency per week: 2 times.
Load adjustment: Aerobic: according to HRR from 55 to 75/80%. 8 levels were determined: A:
55%, B: 55%, C: 55%, D: 55%/65%, E: 65%, F: 65%/75%, G: 75% and H: 75%/85%. The duration was
of 24 min at an A level and 30 min during rest. Resistance: increased from 2 to 3 sets, from 12 to 15
repetitions and at a weight of 5 to 12 lbs. for men, and 2 to 10 lbs. for women.
J. Clin. Med. 2022, 11, 5091 6 of 15

Table 1. Cont.

1. Body composition: BMI, fat mass in %.

(Bioelectrical impedance analysis).
Outcome measurements 2. Functional capacity: 6MWT, chair stand test, half squat test, arm curl test.
3. Quality of life: WRQOL.
4. Surgical objectives: not studied in the research.
Global risk bias High.
[15] Baillot et al. (2018)
Randomization Used software stratified by sex and maximum aerobic capacity (> o ≤ 7 MET).
25 participants: 5 men—20 women.
Institution: Centre hospitalier universitaire de Sherbrooke (CHUS), Quebec.
Country: Canada.
Inclusion criteria: candidates to a BS, 18-year-old or older, both sexes.
Participants
Exclusion criteria: participants with comorbidities that prevent their participation in the
prehabilitation program like a medical contraindication to practice physical activity, functional
limitations that do not allow them to perform the 6MWT, not understanding the French language,
or decompensated neuro-psychiatric pathology.
Gym program:
1. Warm up: 10 min.
2. Aerobic phase: 30 min of exercise on the treadmill, walking circuit, arm ergometer, elliptical
machine, aerobic dance.
3. Resistance phase: 20 to 30 min with small equipment, elastic bands, medicine balls, dumbbells,
sticks.
Intervention
4. Cool down: 10 min.
Total days of training: 36.
Intervention duration: 12 weeks.
Frequency per week: 3 times.
Load adjustment: Aerobic: according to a HRR from 55 to 75/80% (there are no more details in the
article).
1. Body composition: BMI, free fat mass in %.
(Bioelectrical impedance analysis).
Outcome measurements 2. Functional capacity: 6MWT, half squat test.
3. Quality of life: WRQOL.
4. Surgical objectives: not studied in the research.
Global risk bias Uncertain.
[16] Funderburk
et al. (2010)
Randomization Unexplained.
7 participants: 1 man, 6 women.
Institution: Hospital Pitt County Memorial, Rehabilitation center, Greenville.
Participants Country: United States of America.
Inclusion criteria: candidates to a BS, 18 years old or older, both sexes.
Exclusion criteria: no reports in the article.
Program of the institution:
The program included a warmup with exercises (walking in the water), strength and resistance
exercises, and Ai Chi exercises for balance, core strengthening, and relaxation. Ai Chi is an aquatic
exercise that was designed to increase relaxation, range of motion, and mobility. It is performed
standing with the water at shoulder level using a combination of deep breathing and complete slow
Intervention movements of the lower and superior extremities, as well as the torso. (There are no more details in
the article).
Total days of training: 24.
Intervention duration: 12 weeks.
Frequency per week: 2 times.
Load adjustment: not detailed in the article.
J. Clin. Med. 2022, 11, 5091 7 of 15

Table 1. Cont.

1. Body composition: not studied in the article.

2. Functional capacity: 6MWT, chair stand test, postural stability test, abdominal strength, core
Outcome measurements flexor strength, modified push up test.
3. Quality of life: SF 36.
4. Surgical objectives: not studied in the research.
Global risk bias Uncertain.
[17] Marcon et al. (2017)
Randomization In blocks of 12 participants.
57 participants: 6 men—51 women.
Institution: Hospital de Clinicas de Porto Alegre, Porto Alegre.
Country: Brazil.
Inclusion criteria: candidates to a BS, 18 years old or older, both sexes.
Participants Exclusion criteria: participants with comorbidities that prevent their participation in the
prehabilitation program, participating in another supervised exercise program, patients with a class
III or IV of heart functional capacity, orthopedic problems, severe retinopathy, severe neuropathy,
drug addiction, severe mental illness, severe metabolic decompensation (250 mg/DI of blood
glucose, systolic pressure over 200 mmHg, diastolic pressure over 100 mmHG).
Gym program:
Included aerobic exercise and stretching, intensity was measured by Borg’s scale, using a range
between 2 to 4, considering it low to moderate intensity respectively. Arm and leg movements were
alternated, moving to simulate walking. Stretching included: arms, legs, torso, and neck for 6 min
Intervention after the aerobic phase in each session. (There are no more details in the article).
Total days of training: 32.
Intervention duration: 16 weeks.
Frequency per week: 2 times.
Load adjustment: not detailed in the article.
1.- Body composition: BMI.
(Bioelectrical impedance analysis)
Outcome measurements 2.- Functional capacity: 6MWT, VO2 max from equations after the test.
3.- Quality of life: not studied in the research.
4.- Surgical objectives: not studied in the research.
Global risk bias Uncertain.
BS: bariatric surgery, BMI: body mass index, 6MWT: 6-min walk test, OSQOL: Obesity-Specific Quality of life,
HRR: heart rate reserve, WRQOL: Weight-Related Quality of Life, SF 36: quality of life questionnaire related
to health.

3.3. Participants
A total of 139 participants were enrolled in the five selected studies. The data from
115 participants were used for the meta-analysis on the body composition (BMI) [11,15,17,18],
75 participants for the fat mass percentage (FM%) [11,15,18], 46 for the free fat mass
(FFM Kg) [15,18], 61 participants for the meta-analysis of the 6MWT [17,18] and 53 par-
ticipants for the meta-analysis of the quality of life total score [15,16,18]. Regarding the
demographics characteristics of the included studies, the sample size varied between 7 and
57 participants, the age ranged between 28 and 54 years old, 116 participants were women
and all the studies included men.

3.4. Types of Intervention/Exposition

The duration of the intervention programs in the included studies ranged from 8 to
16 weeks. Twelve weeks of intervention were used in three out of the five articles [11,15,16].
One study had an intervention session frequency of three times a week [15] and twice a
week. The duration of each session varied between 25 and 80 min, and the location was ei-
ther a hospital gym or an educational institution where the researchers belonged [11,15–18].
J. Clin. Med. 2022, 11, 5091 8 of 15

In regards to the type of training, the combination of aerobic and resistance exercise
was used in three studies; the other two used aerobic [11] and resistance [18] training sepa-
rately. The average amount of sessions was 26.4, with a range between 16 and 32 sessions.

3.5. Types of Comparator/Control

Only one study did not use any kind of intervention as a control [16]. Standard care
was used for the rest of the studies, counseling being the one used most. One study added
cognitive–behavioral therapy to the standard care [17].

3.6. Risk of Bias Evaluation

Figures 2 and 3 show detailed results of the general risk of bias evaluation and the
evaluation per study, respectively. The randomization generation sequence (selection bias)
was judged as a low risk in all the included studies. On the other hand, the selective
reporting data (report bias) was classified as an uncertain risk in all the studies. A high
risk of bias can be noted in 20% of the included articles for the following items: incomplete
results data (attrition bias), blinding of the participants and personnel (performance bias)
and for other biases.

Figure 2. Evaluation of the general risk of bias.

J. Clin. Med. 2022, 11, 5091 9 of 15

Figure 3. Risk of bias evaluation per study [11,15–18]. Red (-) = high risk of bias; Yellow (?) = un-
known risk of bias; Green (+) = low risk of bias.

3.7. Prehabilitation Effects on the Outcome Measurements

3.7.1. Body Composition
Four studies measured the body composition and reported the BMI [11,15,17,18],
FM% [11,15,18] or FFM, expressed in kilograms [15,18]. Other indexes were reported, such
as abdominal fat in percentage, abdominal muscular mass in kilograms and fat mass in
kilograms. However, they were not used for the meta-analysis, since it was only one
study [18]. Overall, the results indicated no significant effect of prehabilitation in favor of
the experiment or controls for body composition indexes (p > 0.05). Figure 4 shows the
forest plot for BMI using the random effects model to compare the experimental versus
control groups. The results showed a pooled effect of −0.71 (IC95% : −1.55 to 0.1; p = 0.09).
The heterogeneity was 76%, and the quality of evidence was very low (Table 2).

Figure 4. Forest plot of the body composition and the BMI subgroup [11,15,17,18].
J. Clin. Med. 2022, 11, 5091 10 of 15

Table 2. Quality of evidence for the body composition, BMI, FM% and FFM Kg.

Certainty Assessment No. of Patients Effect

Aerobic Physical Certainty

Standard
No. of Other Consid- Exercise, Relative Absolute
Study Design Risk of Bias Inconsistency Indirectness Imprecision Care (no
Studies erations Resistance or (95% CI) (95% CI)
Exercise)
Both

SMD 0.71 SD
randomised fewer ⊕###
4 Serious a Serious b not serious Serious c none 54 61 -
trials (1.55 fewer to Very low
0.12 more)
SMD 0.38 SD
randomised more ⊕⊕⊕#
3
trials Serious d not serious not serious not serious none 39 36 -
(0.47 fewer to Moderate
1.85 more)
SMD 0.41 SD
randomised fewer ⊕⊕⊕#
2 Serious e not serious not serious not serious none 24 22 -
trials (1 fewer to 0.18 Moderate
more)

a Downgraded one level due to risk of bias (>25% of the participants were from studies with a high risk of
bias). b Downgraded one level due to clear inconsistency of results. c Downgraded one level due to imprecision.
d Downgraded one level due to risk of bias (>25% of the participants were from studies with a high risk of bias).
e Downgraded one level due to risk of bias (both studies with uclear risk of bias).

Regarding the effect of an intervention on the FM% (Figure 5), the three studies
included in the analysis resulted in a pooled effect of 0.38 (CI95% : −0.08 to 0.84; p = 0.11).
The heterogeneity was 0%, and the quality of the evidence was moderate (Table 2).

Figure 5. Forest plot of the body composition for the FM% subgroup [11,15,18].

Figure 6 shows the analysis of the FFM kg subgroup. The pooled effect size was −0.41
(IC95%: −1.00 to 0.18; p = 0.17) and a heterogeneity of 0%, with a moderate quality of
evidence (Table 2).

Figure 6. Forest plot of the body composition for the FFM Kg subgroup [11,18].

3.7.2. Functional Capacity

All studies evaluated the functional capacity. The 6MWT was the most used test. Two
studies reported the results as the distance traveled in meters [17,18] and one in the number
of total steps [16]. Baillot studies [11,15] did not show the values for the test results, which
is why they were not included in the meta-analysis.
The VO2 max was an outcome reported for only one study, which was estimated from
a 6MWT equation [17]. Other indicators were used for the outcome report: the chair stand
test [11,15,17,18], postural stability test, abdominal strength, core flexor strength and the
modified push-up test were not analyzed statistically.
Figure 7 and Table 3 show the random effect analysis of the functional capacity for the
6MWT and the quality of evidence, respectively. The pooled effect was 2.59 (IC95% :1.89–3.30;
J. Clin. Med. 2022, 11, 5091 11 of 15

p < 0.0001) in favor of exercise, showing a low heterogeneity (I2 = 0%) and high quality
of evidence.

Figure 7. Forest plot of the functional capacity for the 6MWT [17,18].

Table 3. Quality of evidence for the functional capacity of the 6MWT.

Certainty Assessment No. of Patients Effect

Aerobic Certainty
Physical Standard
No. of Other Consid- Relative Absolute
Study Design Risk of Bias Inconsistency Indirectness Imprecision Exercise, Care (no
Studies erations (95% CI) (95% CI)
Resistance or Exercise)
Both

SMD 2.59 SD
randomised more ⊕⊕⊕⊕
2 not serious not serious not serious not serious none 33 28 -
trials (1.89 more to High
3.3 more)

3.7.3. Quality of Life

Four studies evaluated the quality of life [11,15,16,18]: the SF-36 questionnaire, Weight-
Related Quality of Life (WRQOL) and Obesity Specific Quality of Life (OSQOL) were used.
Baillot et al. (2016) [11] did not report the post-intervention values, so it was not included in
the meta-analysis. The SMD was used to combine the results of the three included studies.
The random effect model resulted in a pooled effect size of 0.88 (CI95% : 0.23–1.99; p = 0.12;
Figure 8), and the quality of evidence was moderate (Table 4).

Figure 8. Forest plot of the quality of life total score [15,16,18].

Table 4. Quality of evidence for the quality of life total score.

Certainty Assessment No. of Patients Effect

Aerobic Certainty
Physical Standard
No. of Other Consid- Relative (95% Absolute
Study Design Risk of Bias Inconsistency Indirectness Imprecision Exercise, Care (no
Studies erations CI) (95% CI)
Resistance or Exercise
Both

SMD 0.88 SD
randomised more ⊕⊕⊕#
3 seriousa not serious not serious not serious none 28 25 -
trials (0.23 fewer to Moderate
1.99 more)

3.7.4. Surgical Outcomes

No study reported the results for this outcome measurement.

4. Discussion
This systematic review’s objective was to determine the effect of prehabilitation on the
body composition, functional capacity, quality of life and surgical outcomes in patients who
J. Clin. Med. 2022, 11, 5091 12 of 15

are candidates for bariatric surgery. In the last 10 years, a series of studies have evaluated
the effects of physical training programs in the context of BS; most of which were done after
the surgery. To the best of our knowledge, only two reviews [19,20] reported the effects
of exercise on BS candidates in some variables considered in this study, but they did not
perform a meta-analysis. Moreover, only two studies included in the previous reviews
were RCTs, strengthening the relevance of the present study.
The results of this systematic review of RCTs showed that supervised exercise as
prehabilitation before BS has positive effects on the body composition (i.e., BMI, FM% and
FFM Kg); functional capacity (6MWT) and quality of life. In this sense, our results corrobo-
rate the findings of previous systematic reviews on this subject [19,20], who reported, in a
descriptive manner, similar results.
The international guidelines for the current treatment recommend that exercise pro-
grams for weight loss in obesity prioritize continuous aerobic exercise with a moderate
intensity and complement this approach, whenever possible, with resistance training [21].
Although these recommendations are for people who are in nonsurgical treatment for
obesity, aerobic exercise was the mostly used intervention modality in the included studies.
Three studies combined aerobic and resistance training [11,15,16], one study used only
resistance training [18] and the other one used only aerobic exercise [17]. On the other
hand, the intensity was heterogenous among the included studies. Regarding the intensity
of aerobic exercise, two studies prescribed intensities ranging from 55% to 75/80% of the
reserve heart rate [11,15], one study prescribed the exercise intensity ranging from 2 to 4 on
the Borg CR10 scale [17] and one did not present details on the exercise intensity [16]. For
resistance training, one study prescribed exercise at 50% of one maximal repetition [18],
two studies prescribed the resistance intensity according to sex [11,15] and one study did
not report details on the intensity prescription [16]. The study that found the greatest
improvement on the BMI prior to BS was Marcon et al. (2017) [17], while the greatest
improvement in the quality of life was that reported by Arman et al. (2021) [18]. In ad-
dition, both studies [17,18] reported significant improvements on the functional capacity.
Therefore, considering the protocols are mostly heterogenous among the included studies,
it is not possible to conclude what type of training and intensity are the most suitable and
effective for BS candidates. Future RCT studies should address this subject to better guide
clinicians during prehabilitation.
Regular physical exercise has several effects on metabolism [22]. It is documented that,
on obese people, aerobic training at a moderate intensity improves many comorbidity mark-
ers associated with it, such as glucose metabolic alteration, dyslipidemia and hypertension,
as well as those indicating cardiovascular disease risk factors (e.g., systematic inflammation,
oxidative stress and diabetes) [22,23]. Moreover, it also increases free fatty acids oxidation
and reduces the total fat and visceral fat [24]. At a muscular level, the increase of the
mitochondrial content as an effect from aerobic training at a moderate intensity has a
series of metabolic effects (e.g., a higher rate of fatty acid oxidation, a higher breakdown
of carbohydrates and a better glucose uptake in the cells, among others), contributing to
improving their performance during exercise and, therefore, functional capacity [25]. Those
factors could explain the results found in this systematic review.
Regarding the quality of life, the current results corroborated the findings of Car-
raça et al. (2021) [26]. The authors conducted a systematic review and meta-analysis on
the effects of exercise on the quality of life and other psychosocial variables in participants
overweight and obese. The results showed that exercise has a positive effect on the quality
of life. Regular physical exercise helps in treating depression and anxiety; reduces stress
levels, improves sleep quality and has positive effects on the performance of daily life
activities, which translates to a better quality of life for people with obesity [26].

5. Study Limitations
Although this systematic review and meta-analysis has methodological strengths,
some limitations must be mentioned. First, the search for information was performed
J. Clin. Med. 2022, 11, 5091 13 of 15

by only one researcher (AH); however, the terms and search strings were defined by the
researchers in collaboration with a university-based librarian with experience in systematic
reviews. Second, the fact that there are a limited number of studies that evaluate preop-
erative interventions can influence the meta-analysis results. Consequently, the results
are not conclusive yet. Finally, these results show evidence of the need for studies that
include a greater number of participants and other relevant variables such as postoperative
complications, days of hospital stay, the need for rehospitalization within 30 days after the
surgery, pain tolerance, etc.

6. Conclusions
Prehabilitation has positive effects on the body composition, functional capacity and
quality of life in patients who are candidates for bariatric surgery. Apparently, supervised
aerobic training at a frequency of two times a week and a duration of 45–60 min per session
for 12 weeks is the most preferred protocol used for this population. However, there is still
a lack of research studying the effects of exercise as a prehabilitation on surgical outcomes.

Author Contributions: Conceptualization: A.H.-S., A.R.Z., G.A.-F.; methodology development:

A.H.-S., G.W., G.A.-F.; Risk of Bias Assessment: A.H.-S., G.A.-F., G.W.; Evaluation of the Quality
of Scientific Evidence: A.H.-S., A.R.Z.; Meta-analysis: A.H.-S., A.R.Z.; Data interpretation: A.H.-S.,
G.A.-F., G.W., N.N.J., A.R.Z.; Writing—original draft preparation: A.H.-S., G.A.-F., G.W., N.N.J.,
A.R.Z.; Writing—review and editing: A.H.-S., G.A.-F., G.W., N.N.J., A.R.Z. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: All data are available upon request to the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations

BS Bariatric surgery.
ERAS Enhanced recovery after surgery.
6MWT Six-minute walking test.
VO2 max Maximal oxygen uptake.
GRADE Grading of recommendations assessment, development, and evaluation.
SMD Standard mean differences.
CORE Core muscles of the body.
BMI Body mass index.
OSQOL Obesity Specific Quality of life.
HRR Heart rate reserve.
WRQOL Weight-Related Quality of Life.
SF 36 Health-related quality of life questionnaire.
FM% Fat mass in percent.
FFM Kg Fat free mass in kilograms.
CI Confidence interval.
RCTs Randomized control trials

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