articles nature publishing group

Bariatric Surgery

High-Volume Exercise Program in Obese

Bariatric Surgery Patients: A Randomized,
Controlled Trial
Meena Shah1–3, Peter G. Snell4, Sneha Rao1,2, Beverley Adams-Huet4,5, Claudia Quittner1,2,
Edward H. Livingston4,6 and Abhimanyu Garg1,2,4

Weight regain is a problem among many bariatric surgery patients. Whether a high-volume exercise program (HVEP),
a strategy to limit weight regain, is feasible in these patients is unknown. The feasibility of an HVEP in obese post-
bariatric-surgery patients was determined by randomizing 33 Roux-en-Y gastric bypass (RYGB) and gastric banding
(GB) surgery patients with a mean BMI of 41 ± 6 kg/m2 to an HVEP or control group for 12 weeks. The HVEP group
was instructed to expend ≥2,000 kcal/week in moderate-intensity exercise. All patients were counseled to limit energy
intake. Treatment effect was assessed by repeated measures analysis. During the last 4 weeks of the study, 53%
of the HVEP group expended ≥2,000 kcal/week and 82% expended ≥1,500 kcal/week. Step count, reported time
spent and energy expended during moderate physical activity, maximal oxygen consumption relative to weight, and
incremental area under the postprandial blood glucose curve were significantly improved over 12 weeks in the HVEP
group compared to controls (group-by-week effect: P = 0.009–0.03). Both groups reported significant improvement
in some quality-of-life scales. Changes in weight, energy and macronutrient intake, resting energy expenditure (REE),
fasting lipids and glucose, and fasting and postprandial insulin concentrations were not different between the two
groups. HVEP is feasible in about 50% of the patients and enhances physical fitness and reduces postprandial blood
glucose in bariatric surgery patients.

Obesity (2011) 19, 1826–1834. doi:10.1038/oby.2011.172

Introduction
Severe obesity (defined as BMI of ≥40 kg/m2) is a significant
public health problem in the United States. According to a
national survey conducted in the year 2007–2008, nearly 6% of
US adults are severely obese (1). In addition, from the year 2001
to 2005, the prevalence of severe obesity has increased twice
as fast compared with the prevalence of a BMI ≥30 kg/m2 (2).
Severe obesity is associated with a number of major comorbidi-
ties (3) and markedly lessens life expectancy (4). It is also asso-
ciated with a poor quality of life (QOL) (5).
Dietary therapy has been ineffective in treating severe obes-
ity in the long term (6). This as well as the above issues and the
advent of laparoscopic bariatric surgery procedures has led to
an exponential increase in Roux-en-Y gastric bypass (RYGB)
and gastric banding (GB) surgeries (7). Although these surger-
ies lead to substantial excess weight loss and complete resolu-
tion or improvement of comorbidities (8–10), the long-term
results are more modest with considerable weight regain and
attenuation in the recovery from comorbidities (11,12).
Studies in non-bariatric-surgery patients (13,14) and data
from the National Weight Control Registry (15) have suggested
that individuals may need to expend ≥2,000 kcal/week in mod-
erate-intensity exercise in order to lose and/or maintain weight
loss. Whether bariatric surgery patients, many of whom are
severely obese even after weight loss, can exercise at this level
is not clear. According to a case–control study (16) in which
bariatric surgery patients were compared with sex- and weight-
matched controls, only 30% of the former group reported
expending ≥1,500 kcal/week in exercise compared to 70% of
the latter group. Similarly, according to another case–control
study (17) in which bariatric surgery patients who had lost a
large amount of weight were compared with subjects who had
lost a similar amount of weight through nonsurgical means,
approximately 30% of the former group reported expending at

1
Division of Nutrition and Metabolic Diseases, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA; 2Center for Human Nutrition, University of
Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA; 3Department of Kinesiology, Texas Christian University, Fort Worth, Texas, USA; 4Department of Internal
Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA; 5Department of Clinical Sciences, University of Texas Southwestern Medical
Center at Dallas, Dallas, Texas, USA; 6Department of Gastrointestinal and Endocrine Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas,
USA. Correspondence: Meena Shah (meena.shah@utsouthwestern.edu) or (m.shah@tcu.edu) or Abhimanyu Garg (abhimanyu.garg@utsouthwestern.edu)
Received 10 October 2010; accepted 8 May 2011; published online 16 June 2011. doi:10.1038/oby.2011.172

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least ≥2,000 kcal/week in physical activity compared to about
60% of the latter group. Several case series studies on the other
hand, generally noted a higher reported participation rate
in exercise in post-bariatric-surgery patients but the energy
expended during exercise was not given (18–23) and the infor-
mation on the type, duration, and intensity of exercise was not
always provided (18,19,22). Also none of the above studies used
an objective method of assessing physical fitness and the studies
were not randomized, controlled trials thus preventing deter-
mination of whether an exercise program is feasible in this pop-
ulation. These limitations make it difficult to interpret whether
bariatric surgery patients can exercise at a certain level. Our
study was designed to assess the feasibility of a high-volume
exercise program (HVEP) in obese bariatric surgery patients
in a randomized, controlled trial. The level of exercise training,
and thus physical fitness, was assessed using an objective meas-
ure. It was hypothesized that the exercise goals would be met
by most of the subjects in the HVEP group and that it would
lead to improvement in fitness in these subjects compared to
the controls. The secondary outcome goals were weight loss,
comorbidities, and health-related QOL.
Methods and Procedures
Subjects
We recruited 33 RYGB and GB surgery patients for the study. Eligibility
requirements included meeting the class 2 (BMI: 35.5–39.9 kg/m2) or
class 3 (BMI: ≥40 kg/m2) obesity criteria, exercising <20 min/day within
the previous 3 months, undergone bariatric surgery at least 3 months
earlier, and being 18–65 years old. Patients were not eligible for the study
if they weighed >180 kg, had functional limitations, such as not being
able to climb 10 stairs or walk for 0.4 km (0.25 miles), due to arthritis
or other musculoskeletal cause, were on weight loss medications, had
serious cardiovascular disease, uncontrolled hypertension, hematocrit
<30%, chronic kidney disease, untreated thyroid disorders, pulmonary
disease severe enough to preclude participation in exercise training, or
major neuropsychiatric illnesses impeding competence or compliance,
or were pregnant, lactating, or taking recreational drugs.
The study was conducted at the Clinical and Translational Research
Center and the St Paul Fitness Center at UT Southwestern Medical Center
at Dallas. The protocol for this study was approved by the institutional
review board, and all patients gave written informed consent.
Experimental design
The subjects were randomized to a HVEP (n = 21) or a control (n = 12)
group for 12 weeks using a 2:1 randomization ratio and stratified by the
type of surgery.
Exercise intervention
The exercise goal in the HVEP group was to expend ≥2,000 kcal/week in
moderate-intensity aerobic exercise at 60–70% of maximal oxygen con-
sumption (VO2max). The subjects were instructed to achieve these goals
gradually and were asked to expend 500 kcal during the first week and
increase by 500 kcal every week until they achieved their goal of ≥2,000
kcal/week. Each subject was asked to exercise on the treadmill at a cer-
tain speed and grade and on the cycle ergometer or rowing machine at
a particular wattage that would correspond to 60–70% of her/his meas-
ured VO2 . When exercising elsewhere, they were asked to use similar
max
equipment and follow the same individualized protocol used in the fit-
ness center. Subjects who preferred to walk outside or on the walking
track were asked to measure the distance that they walked and asked to
complete this distance in a time period to achieve a pace associated with
an intensity of 60–70% of the measured VO2max. Once the ­intensity was
achieved and the subjects became more physically fit, they were asked to
obesity | VOLUME 19 NUMBER 9 | september 2011
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Bariatric Surgery
increase their intensity in order to maintain the same level of perceived
exertion. The subjects were asked to exercise at least 5 days a week. The
exercise was partially supervised and the subjects were asked to come to
the fitness center at least once or twice a week. About a third of the subjects
came to the fitness unit once or twice a week and about a third performed
all of their exercise under our supervision. The exercise supervision was
led by one of the investigators (P.S.) and one or more of the other inves-
tigators were always present during the supervised sessions. Energy
expenditure per week was calculated approximately from the work data
shown on the exercise equipment and from the duration and distance of
walking relative to body weight. Exercise away from the fitness center was
monitored by asking the subjects to keep an exercise diary and/or using
heart rate monitors (Polar Vantage XL monitors, Kempele, Finland). The
subjects were asked to bring the diaries and heart rate monitors to the
fitness center or mail the diaries every 2 weeks. The participants were
provided feedback on how much energy they were expending through
the logs that were kept at the fitness center and using the exercise diaries
that they kept when exercising away from the fitness center.
Diet intervention
To optimize their diet and prevent nutritional deficiencies, the sub-
jects in both the groups were instructed to follow the dietary guide-
lines developed for post-bariatric-surgery patients by the American
Society for Metabolic and Bariatric Surgery and other groups (24,25).
The instructions were provided through individual dietary counseling.
They were asked to limit their energy intake to about 1,200–1,500 kcal/
day. This was achieved by limiting portion size, energy-dense foods, and
energy-containing drinks. They were also asked to chew foods thor-
oughly and take at least 20 min to eat the main meal, not to drink dur-
ing and 30 min before and after a meal to prevent vomiting, diarrhea,
and quick return to hunger, consume >60 g of protein per day to pre-
serve lean body mass (LBM), consume the protein food sources before
the fat and carbohydrate food sources, consume at least 5 servings of
fruits and vegetables, and drink 2 liter/day (64 oz) of fluid in the form of
frequent small amounts of water throughout the day (24,25). The RYGB
surgery patients were asked to avoid food and drinks with added sugar
and fruit juice to prevent the dumping syndrome (24,25). To improve
compliance to the dietary recommendations, the subjects were asked to
keep a daily diet diary, which was used by the investigators to provide
individual feedback every 2 weeks. Lastly, all the subjects were asked to
take multivitamin and mineral supplements as recommended for bari-
atric surgery patients (24,25) with the RYGB surgery patients requir-
ing more extensive supplement therapy because of their greater risk for
nutritional deficiencies.
Behavioral therapy
Behavioral therapy related to exercise was provided to the HVEP group
on an individual basis, by one of the authors (M.S.), and included goal
setting, self-monitoring, cognitive–behavioral strategies, and problem
solving and relapse prevention. The behavioral therapy was provided
every 2 weeks either in conjunction with the supervised exercise ses-
sions or by telephone. Behavioral therapy related to diet was provided
to subjects in both the groups on an individual basis and by the same
author, and included all of the above strategies plus stimulus control,
eating behavior, and stress management.
Measurements
All of the following measurements were collected at baseline, 6 and
12 weeks except VO2max, dual-energy X-ray absorptiometry, and
oral ­glucose tolerance test (OGTT), which were measured only at
baseline and 12 weeks and demographic characteristics and health
history, which were collected at baseline. Our primary outcome vari-
able was VO2 . max
Physical fitness, physical activity, REE, and blood pressure
Physical fitness was assessed by measuring VO2max (ml/kg/min) using
a graded maximal exercise test on a treadmill and was supervised by a
physician who monitored a 12-lead ECG. To establish the treadmill
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Bariatric Surgery
speed for the test, subjects performed a short walking warm-up at 0%
grade and the speed was then increased until a steady-state heart rate
of 60% of age-predicted maximum or a rating of perceived exertion
of 11–13 (fairly light to somewhat hard physical activity) on the Borg
scale (26) was maintained for 4 min. After a short recovery and stretch-
ing period, the test commenced at the previously determined speed
and the grade was elevated 2% in 2-min stages until exhaustion. Blood
pressure, heart rate, and rating of perceived exertion were measured
during the last 30 s of each stage. The test continued until the par-
ticipant reached volitional fatigue or met the other standard stopping
criteria (27).
Physical activity levels were assessed by instructing the subjects to wear
a pedometer (DIGI WALKER SW-200; New Lifestyles, Lees Summit,
MO) for 7 days each at baseline and 6 and 12 weeks. It was also assessed
by interviewer administered 7-day physical activity recall, a validated tool
(28) that collects information on time spent in sleep, moderate, hard, and
very hard activities. Data from the 7-day physical activity recall were used
to calculate the energy expended (kcal/kg/day) in sleep, light, moderate,
hard, and very hard activities by multiplying the reported average number
of hours per day spent at each activity level by the metabolic equivalent
(ratio of work metabolic rate and resting metabolic rate) for that activity
(1, 1.5, 4, 6, and 10, respectively).
Resting energy expenditure (REE) was assessed by indirect calorimetry
(Deltatrac II; Sensormedics, Yorba Linda, CA) during the fasting condi-
tion using a protocol similar to that described elsewhere (29). Resting
blood pressure was assessed three times each at baseline and 6 and 12
weeks and prevalence of hypertension was diagnosed using the guide-
lines by the Joint National Committee 7 report on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (30).
Dietary intake
Dietary intake was assessed by 3 day (2 week days and one weekend day)
food record, a validated technique (31). The food records were analyzed
for nutrient intakes using the University of Minnesota Nutrition Data
System for Research, version 5.0–3.5.
Anthropometry and dual-energy X-ray absorptiometry
Weight was measured in light clothing to the nearest 0.1 kg, and height
without shoes and waist and hip circumferences were measured to the
nearest 0.1 cm using standard procedures (32). Body composition was
assessed using dual-energy X-ray absorptiometry (Hologic QDR4500,
Bedford, MA). The dual-energy X-ray absorptiometry measurement
was limited to subjects weighing <136 kg (18 HVEP subjects and 12
controls), the maximum weight supported by the table top.
Lipids, lipoproteins, glucose, and insulin concentrations
A blood sample was drawn after a 12-h overnight fast on 3 days
each at baseline, 6, and 12 weeks for assessment of lipids, lipopro-
teins, glucose, and insulin. Serum total cholesterol, triglycerides, and
high-density lipoprotein cholesterol were analyzed using enzymatic
methods (33) and low-density lipoprotein cholesterol was calcu-
lated. Plasma insulin was measured using radioimmunoassay kits
(Millipore, Billerica, MA).
A standard OGTT with 75 g of oral dextrose (Glucose Drink; Azer
Scientific, Morgantown, PA) was conducted after a 12-h overnight fast in
nondiabetic GB surgery patients. The OGTT was limited to GB subjects
(n = 23) and not conducted in RYGB surgery patients because of their
propensity to develop the dumping syndrome following an oral glucose
load. An intravenous catheter was placed in the forearm vein and blood
was collected for determination of insulin and glucose concentrations
at −30, −15, and 0 min before glucose ingestion, and at 30-min intervals
thereafter for 120 min.
Prevalence of hypercholesterolemia, low high-density lipoprotein
cholesterol, high non-high-density lipoprotein cholesterol, and hyper-
triglyceridemia was diagnosed using the National Cholesterol Education
Program, Adult Treatment Panel III (NCEP ATP III) guidelines (34),
and type 2 diabetes using the American Diabetes Association and World
Health Organization Expert Committees guidelines (35).
1828
Health-related QOL and current health and medication use
Health-related QOL was assessed using validated questionnaires: SF-36
(the Medical Outcomes Study 36-item Short-Form Health Survey
­questionnaire version 2.0; refs. 36,37) and the IWQOL-L (Impact of
Weight on QOL-Lite; ref. 38). Current health and medication use was
collected by questionnaire.
Statistical analysis
The effect of treatment on the continuous outcome variables was
assessed by mixed-effects models for repeated measures with a
between group factor (HVEP and control group) and a repeated fac-
tor (evaluation week). The difference in response between the two
groups was assessed by using the group-by-week interaction factor
and changes within groups were assessed by tests of the effect slices in
the mixed-effects models for repeated measures analysis. To compare
plasma glucose and insulin concentrations during the OGTT test, the
incremental area under the curve for these variables was computed
for each subject using the trapezoidal rule and the 12-week difference
from baseline was compared between groups by the nonparametric
Wilcoxon Rank Sum test.
The treatment outcomes reported in this paper are intention-to-treat
analyses and excluded one subject in the HVEP group and four subjects
in the control group who did not provide any follow-up data after base-
line. Only nonadjusted results are reported in the paper because adjusting
for age, baseline BMI, type of surgery, and banding adjustments did not
change the results. Variables that did not satisfy the analysis assumptions
(triglycerides, insulin, and glucose concentrations) were log-transformed
before analyses. Group differences at baseline were assessed by two-sam-
ple t-tests for continuous variables and Fisher’s exact tests for categorical
variables. All data are reported as means and standard deviations unless
otherwise noted. All analyses were carried out using the SAS statistical
software, version 9.2 (SAS Institute, Cary, NC).
Results
Baseline participant characteristics
Baseline characteristics are shown in Table 1. Mean BMI was
>40 kg/m2 in both groups and mean age was 53.9 years in the
control group and 47.3 years in the HVEP group. More than
90% of the subjects were female. Most of the subjects were
non-Hispanic whites or African Americans and had under-
gone the GB surgery. Less than 20% of the subjects were cur-
rent smokers. The average duration since surgery ranged from
3 months to 3.5 years in the control group and from 3 months
to 8.5 years in the HVEP group. None of these variables were
different between the two groups. Presence of comorbidities
was also not different except for the prevalence of diabetes,
which was significantly higher in the control group compared
to the HVEP group.
Subject attrition and problems during exercise
Four out of 12 subjects in the control group did not provide
any data after baseline. Three of these four subjects dropped
out because they would have preferred to be in the exercise
group and the fourth subject did not have time for the study.
Five out of 21 subjects in the HVEP group also did not com-
plete the study. Four of these five subjects provided data at
both baseline and 6 weeks whereas one provided data at only
baseline. The reason for the drop out in the HVEP group was
because they did not have enough time to exercise. Excluding
the four subjects in the control group and one subject in the
HVEP group who did not provide any data after baseline from
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our data set (intention-to-treat analysis data set) did not affect not encounter any major problems during exercise other than
the baseline BMI and prevalence of type of surgery but age the occasional muscle or joint soreness.
was significantly higher in the control group compared to the
HVEP group (P = 0.02). The subjects in the HVEP group did Exercise energy expenditure, moderate physical
activity METs, step count, VO2 , and REE
max
At 4 weeks, 30% of the subjects in the HVEP expended ≥2,000
Table 1  Baseline characteristics of the subjects
kcal/week and 55% expended ≥1,500 kcal/week. During
Control High-volume the second 4-week period, 40% of the subjects in the HVEP
group exercise
(n = 12) group (n = 21) P value
expended ≥2,000 kcal/week and 65% expended ≥1,500 kcal/
week and the respective percentages for the last 4 weeks were
BMI (kg/m ) (mean ± SD)
2
41.0 ± 3.7 42.4 ± 6.9 0.87
53 and 82% (based on the mean of each 4-week period).
Age, years (mean ± SD) 53.9 ± 8.8 47.3 ± 10.0 0.07 The number of steps/day increased from about 5,500 steps
Female (%) 92 90 1.0 at baseline to nearly 10,000 steps/day at 12 weeks in the
Ethnicity (%) HVEP group and increased only slightly in the control group
  White, non-Hispanic 75 43 0.25 (Figure  1a). The group-by-week interaction (P  =  0.03) and
within-group change in the HVEP group (P < 0.0001) were
  African American 25 48
statistically significant.
  Hispanic 0 9 Based on the 7-day physical activity recall, the reported time
Type of surgery (%) spent and energy expended during moderate physical activity
  GB 67 71 1.0 increased by more than three times over 12 weeks in the HVEP
  RYGB 33 29 group but remained the same in the control group compared
to respective baseline values (Table  2). There was a signifi-
Months since bariatric surgery 19 (3–42) 17 (3–102) 0.81
(median and range) cant group-by-week interaction (P = 0.02) and within-group
change in the HVEP group (P < 0.0001) but not in the con-
Current smoker (%) 8 19 0.63
trol group (P = 0.99). There was no group-by-week interaction
Type 2 diabetes (%) 25 0 0.04
for the reported time spent and energy expended during light
Hypertension (%) 75 38 0.07 physical activity. The median values for time spent in vigorous
Hypercholesterolemia (%) 25 52 0.16 (hard and very hard) physical activity and the energy expendi-
Low HDL cholesterol (%) 42 33 0.72 ture related to these activities were zero for both groups and at
High non-HDL cholesterol (%) 42 52 0.72
all time points.
VO2max relative to body weight, the primary outcome vari-
Hypertriglyceridemia (%) 33 24 0.69
able, increased by 10% in the HVEP group (baseline: 17.4 ± 3.3
GB, gastric banding; HDL, high-density lipoprotein; RYGB, Roux-en-Y gastric (mean  ±  SD) ml/kg/min; 12 weeks: 19.2  ±  4.2 ml/kg/min)
bypass.
BMI, age, and duration since bariatric surgery were compared between the two and did not change much in the control group (baseline:
groups by two-sample t-tests and gender, ethnicity, type of surgery, smoking 17.6 ± 1.4 ml/kg/min; 12 weeks: 17.1 ± 1.7 ml/kg/min) over
status, and prevalence of type 2 diabetes, hypertension, hypercholesterolemia,
low HDL cholesterol, high non-HDL cholesterol, and hypertriglyceridemia were 12 weeks compared to the corresponding baseline values
compared by Fisher’s exact tests. (Figure 1b). There was a significant group-by-week interaction

a Control HVEP b Control HVEP

25,000 32

28
20,000
Step count (steps/day)

24
VO2max (ml/kg/min)

15,000
20

10,000
16

5,000 12

0 0
Baseline Week 12 Baseline Week 12 Baseline Week 12 Baseline Week 12

Figure 1  Changes in step count and VO2max during the study. The individual values and means (horizontal lines) are shown for (a) step count and
(b) VO2max in the control and HVEP groups. Signficant group-by-week interaction and within-group change in the HVEP group was seen for step count
(P = 0.03 and P < 0.0001, respectively) and VO2max (P = 0.009 and P = 0.001, respectively) as evaluated by repeated measures analysis. HVEP, high-
volume exercise program; VO2max, maximal oxygen consumption.

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Table 2 Reported energy expended and time spent during moderate and light physical activity from 7-day physical activity recall
and resting energy expenditure during the study
Control group (n = 8) High-volume exercise group (n = 20)
Variable Baseline 6 weeks 12 weeks Baseline 6 weeks 12 weeks P value
Moderate physical activity
  Energy expenditure 0.3 (0–4.6) 0.0 (0–7.4) 0.4 (0–3.4) 1.1 (0–5.8) 3.5* (0.4–8.2) 4.1** (0–15.0) 0.02
  (kcal/kg/day)
  Time spent (h/day) 0.1 (0–1.1) 0.0 (0–1.9) 0.1 (0–0.9) 0.3 (0–1.5) 0.9* (0.1–2.1) 1.0** (0–3.8)
Light physical activitya
  Energy expenditure 24.9 (22.6–29.4) 25.6 (24.0–27.5) 24.9 (22.9–29.3) 24.9 (19.5–27.2) 24.7 (21.1–26.7) 23.9 (19.9–26.8) 0.85
  (kcal/kg/day)
  Time spent (h/day) 16.6 (15.1–19.6) 17.1 (16–18.3) 16.6 (15.3–19.5) 16.6 (13–18.1) 16.5 (14.1–17.8) 15.9 (13.3–17.9)
Resting energy 1,325 1,340 1,252 1,415 1,390 1,377 0.21
expenditure (kcal/day) (990–1,905) (1,160–1,610) (990–1,583) (1,130–2,093) (1,108–2,172) (1,130–1,955)
Values are shown as medians with minimum and maximum values in parentheses. The median values for energy expenditure and time spent during vigorous (hard and
very hard) physical activity were zero in both groups and at all time points and are not shown in the table. The group-by-time interaction was evaluated by repeated
measures analysis.
a
Light physical activity, as determined by 7-d physical activity recall, encompasses sedentary behaviors such as sitting, standing, pottering, or light housework.
*P < 0.02 for within-group change from baseline to 6 weeks. **P < 0.0001 for within-group change from baseline to 12 weeks.

Table 3 Energy and macronutrient intake during the study

Control group (n = 8) High-volume exercise group (n = 20)
Variable Baseline 6 weeks 12 weeks Baseline 6 weeks 12 weeks P value
Energy intake (kcal/d) 1,618 1,037 1,025 1,566 1,077 1,208* 0.47
(635–3,264) (499–3,222) (612–1,833) (301–2,617) (560–1,684) (664–1,825)
Protein intake (g/d) 65 ± 27 49 ± 15 53 ± 21 66 ± 21 60 ± 17 63 ± 16 0.69
Fat intake (% total energy) 34.6 ± 6.2 32.9 ± 8.5 32.6 ± 9.5 35.5 ± 7.6 31.9 ± 8.6 33.9 ± 9.1 0.76
Values for energy intake are shown as medians with minimum and maximum values in parentheses and those for protein and % energy from fat are shown as
means ± SD. The group-by-time interaction was evaluated by repeated measures analysis.
*P < 0.05 for within-group change from baseline to 12 weeks.

Table 4  Body weight, waist and hip circumference, and body composition during the study
Control group (n = 8) High-volume exercise groupa (n = 20)
Variable Baseline 6 weeks 12 weeks Baseline 6 weeks 12 weeks P value
Body weight (kg) 101.4 ± 8.7 99.6 ± 6.9 96.7 ± 6.7* 110.3 ± 16.6 108.2 ± 16.6 106.1 ± 15.3* 0.46
Waist circumference (cm) 109.2 ± 12.1 109.8 ± 13.2 105.6 ± 9.2 116.3 ± 12.9 113.1 ± 12.9 112.6 ± 11.8 0.30
Hip circumference (cm) 128.5 ± 7.1 127.3 ± 8.7 122.9 ± 8.5** 129.7 ± 13.7 128.3 ± 13.6 126.8 ± 13.7* 0.37
Whole-body fat (%) 46.2 ± 3.6 NA 44.5 ± 5.4 45.0 ± 4.4 NA 44.1 ± 5.5 0.57
Trunk fat (%) 45.4 ± 5.3 NA 43.7 ± 6.8 44.2 ± 3.4 NA 43.8 ± 5.4 0.49
Lean body mass (kg) 51.1 ± 6.7 NA 50.4 ± 5.5 54.9 ± 6.1 NA 54.3 ± 6.2 0.94
Values are shown as means ± SD. The group-by-time interaction was evaluated by repeated measures analysis.
NA, not assessed.
a
Only 14 high-volume exercise subjects underwent body composition assessment by dual-energy X-ray absorptiometry because of weight limitation.
*P < 0.01 for within-group change over 12 weeks. **P < 0.05 for within-group change over 12 weeks.

(P  =  0.009) and within-group change in the HVEP group
(P = 0.001) but not in the control group (P = 0.41).
REE decreased by 2.6% from baseline to 12 weeks in the
HVEP group and by 5.5% over the same time period in the
control group (Table 2). Neither the group-by-week interac-
tion (P = 0.21) nor the within-group changes (P = 0.50 and
P = 0.10 in HVEP and control groups, respectively) were sig-
nificant, however.
Energy and macronutrient intake
Reported energy intake decreased by 358 kcal/day in the HVEP
group and by 593 kcal/day in the control group over 12 weeks
(Table 3). Protein intake was maintained at ≥60 g in the HVEP
group over 12 weeks and tended to decrease by 12–16 g/day to
about 50 g/day in the control group (Table 3). Percent energy
from fat declined slightly in both the groups (Table 2). The
group-by-week interaction or the within-group changes were

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Table 5  Plasma glucose, insulin, and lipid concentrations, and blood pressure during the study
Control group (n = 8) High-volume exercise group (n = 20)
Variable Baseline 6 weeks 12 weeks Baseline 6 weeks 12 weeks P value
Fasting glucose (mg/dl) 107 (87–195) 100 (85–173) 102 (87–154) 91 (77–116) 89 (74–119) 91 (76–112) 0.41
2-h PP glucose (mg/dl) 143 (102–369) NA 143 (81–332) 133 (96–232) NA 119 (82–149) 0.49
Fasting insulin (µU/ml) 17 (7–42) 21 (4–43) 18 (5–41) 17 (8–30) 17 (12–27) 17 (9–39) 0.97
2-h PP insulin (µU/ml) 62 (28–86) NA 72 (36–192) 75 (37–153) NA 76 (23–184) 0.68
Fasting TC (mg/dl) 165 ± 34 164 ± 29 160 ± 28 190 ± 40 184 ± 44 187 ± 36 0.81
Fasting LDLC (mg/dl) 94 ± 31 91 ± 30 89 ± 25 112 ± 37 109 ± 38 106 ± 35 0.94
Fasting HDLC (mg/dl) 51 ± 11 51 ± 11 50 ± 9 55 ± 14 54 ± 14 58 ± 12 0.28
Fasting TG (mg/dl) 104 ± 46 109 ± 47 102 ± 31 109 ± 49 107 ± 50 103 ± 45 0.67
SBP (mm Hg) 113.5 ± 6.4 120.3 ± 11.3 116.2 ± 10.8 119.6 ± 9.6 116.7 ± 11.8 117.6 ± 9.6 0.13
DBP (mm Hg) 71.5 ± 6.4 74.8 ± 8.4 73.1 ± 8.9 76.1 ± 7.2 75.1 ± 7.3 72.2 ± 7.5 0.24
Values for glucose and insulin are shown as geometrical means and ranges and those for lipids and blood pressure are means ± SD. Postprandial glucose and insulin
results were obtained in gastric banding patients only. The group-by-time interaction was evaluated by repeated measures analysis.
DBP, diastolic blood pressure; HDLC, high-density lipoprotein cholesterol; LDLC, low-density lipoprotein cholesterol; PP, postprandial; SBP, systolic blood pressure;
TC, total cholesterol; TG, triglycerides.

a Control HVEP b Control HVEP

16,000 35,000

14,000 30,000

12,000
Glucose iAUC (mg/dl·min)

25,000
Insulin iAUC (µU/ml·min)

10,000
20,000
8,000
15,000
6,000
10,000
4,000

2,000 5,000

0 0
Baseline Week 12 Baseline Week 12 Baseline Week 12 Baseline Week 12

Figure 2  Changes in incremental area under the curve (iAUC) for postprandial blood glucose and insulin levels during the study. Individual values and
geometrical means (horizontal lines) are shown for postprandial blood (a) glucose iAUC and (b) insulin iAUC in the control and HVEP groups. A significant
group-by-week interaction (P = 0.03) was seen for glucose iAUC. HVEP, high-volume exercise program; iAUC, incremental area under the curve.

not significant for any of the variables except energy intake that
reduced significantly within the HVEP group (P = 0.02) but
not in the control group (P = 0.07).
Body weight, waist and hip circumferences,
and body composition
Body weight, and waist and hip circumferences decreased sim-
ilarly in the two groups over 12 weeks (Table 4). Percent total
body fat, percent trunk fat, and LBM also decreased similarly and
slightly in both groups (Table 4). The group-by-week interaction
was not significant for any of these variables but the within-group
changes were significant for body weight and hip circumference
in both the HVEP (P = 0.009 and P = 0.02, respectively) and the
control (P = 0.006 and P = 0.002, respectively) group.
2-h postprandial glucose and insulin concentrations, although
the 2-h postprandial blood glucose response decreased by 11% in
the HVEP and remained the same in the control group (Table 5).
There was a significant group-by-week interaction for the incre-
mental area under the curve postprandial glucose response
(P = 0.03) (Figure 2a) but not insulin response (Figure 2b).
There was a tendency for fasting lipid concentrations and
blood pressure to decline slightly over 12 weeks in both the
groups except high-density lipoprotein cholesterol, which
tended to increase by 3 mg/dl in HVEP group and SBP and DBP,
which tended to increase by 2–3 mm Hg in the control group
compared to the corresponding baseline values (Table 5). The
group-by-week interaction or within-group change was not
statistically significant for any of these variables.

Plasma glucose, insulin, and lipid concentrations Health-related QOL

and blood pressure Data on health-related QOL are presented in Table 6. The HVEP
There was no significant group-by-week interaction or within- group reported significant improvement in 4 of the 5 IWQOL-L
group changes for fasting glucose and insulin concentrations or scales including physical function (P  =  0.049), self-esteem

obesity | VOLUME 19 NUMBER 9 | september 2011 1831

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Table 6  Quality of life during the study

Control group (n = 8) High-volume exercise group (n = 20)
Variable Baseline 6 weeks 12 weeks Baseline 6 weeks 12 weeks P value
IWQOL-L
  Physical function 63 ± 23 71 ± 20 75 ± 17 68 ± 21 75 ± 18 80 ± 20* 0.96
  Self-esteem 50 ± 30 67 ± 30 63 ± 27** 59 ± 24 70 ± 24 80 ± 22*** 0.053
  Sexual life 67 ± 32 86 ± 21 81 ± 20* 68 ± 30 80 ± 26 84 ± 21* 0.43
  Public distress 65 ± 31 76 ± 21 79 ± 19 68 ± 28 77 ± 24 87 ± 18** 0.76
  Work or daily activities 68 ± 25 83 ± 17 85 ± 27* 78 ± 18 84 ± 17 90 ± 13 0.47
  Total score 61 ± 24 74 ± 19 75 ± 19* 67 ± 18 76 ± 16 83 ± 16*** 0.42
SF-36
  Physical functioning 48 ± 5 50 ± 5 50 ± 8 49 ± 9 50 ± 7 52 ± 7 0.48
  Role limitation physical 52 ± 6 54 ± 3 54 ± 4 51 ± 10 51 ± 7 53 ± 6 0.46
  Bodily pain 48 ± 10 51 ± 11 54 ± 8 52 ± 9 51 ± 8 51 ± 8 0.16
  General health 49 ± 10 50 ± 8 53 ± 7 51 ± 8 52 ± 7 55 ± 6 0.86
  Emotional well being 50 ± 8 50 ± 8 50 ± 10 47 ± 11 54 ± 8 57 ± 6** 0.09
  Role limitation emotional 52 ± 7 51 ± 6 51 ± 8 48 ± 14 50 ± 8 52 ± 7 0.77
  Social functioning 45 ± 12 51 ± 6 45 ± 12 47 ± 9 50 ± 9 51 ± 8 0.33
  Energy 49 ± 9 55 ± 11 54 ± 13 46 ± 10 55 ± 8 58 ± 8*** 0.34
  Physical QOL summation 49 ± 6 51 ± 6 53 ± 7 52 ± 9 50 ± 7 52 ± 7 0.06
  Mental QOL summation 49 ± 8 51 ± 8 49 ± 11 46 ± 13 53 ± 8 55 ± 7** 0.15
Values are means ± SD. The group-by-time interaction was evaluated by repeated measures analysis.
IWQOL-L, Impact of Weight on QOL-Lite; QOL, quality of life; SF-36, Short-Form 36.
*P < 0.05 for within-group change over 12 weeks. **P < 0.01 for within-group change over 12 weeks. ***P < 0.001 for within-group change over 12 weeks

(P = 0.0002), sexual life (P = 0.02), public distress (P = 0.003), and
the total score (P = 0.0004) over 12 weeks whereas the control
group reported improvement in self-esteem (P = 0.004), sexual
life (P = 0.04), and work (or daily activities) (P = 0.04) and the
total score (P = 0.012). There was no group-by-week interaction
for any of the scales except the interaction for self-esteem, which
was close to significance (P = 0.05). According to the data from
the SF-36 questionnaire, there was no group-by-week interac-
tion for any of the scales but the HVEP group reported a signifi-
cant improvement in emotional well being (P = 0.001), energy
levels (P = 0.0002), and mental QOL total score (P = 0.006) over
12 weeks whereas QOL in the control group did not change.
Discussion
Our study is the first study to examine the feasibility and effi-
cacy of an HVEP in mostly severely obese bariatric surgery
patients. Our results show that during the last 4 weeks of the
12-week study, about 50% of the subjects were performing a
large volume (≥2,000 kcal/week) of moderate-intensity exer-
cise and >80% were expending at least 1,500 kcal/week. The
increased amount of time spent exercising was not compen-
sated for by reducing physical activity levels at other times of
the day because the step count increased substantially from
about 4,500 steps/day to nearly 10,000 steps/day. The increase
in moderate-intensity exercise was associated with a signifi-
cant 10% increase in VO2max relative to body weight in the
HVEP group and this increase was not related to the number
of months since bariatric surgery was performed. A recent
small study by Stegen et al. (39) in which patients who under-
went RYGB surgery were allowed to choose whether or not to
undergo a 12-week endurance and resistance exercise training
program a month after bariatric surgery, reported no group-
by-time interaction effect, unlike our study, but a within-group
increase (25–26%) in peak VO2max relative to body weight in
both the exercise and control groups. It is not clear why the
control group in their study showed the same improvement
in fitness levels as the exercise group despite adjusting VO2max
for weight loss. In a pre–post study by Sartorio et al. (40),
VO2max relative to body weight increased by 20% in severely
obese non-bariatric-subjects after 3 weeks of endurance train-
ing. The smaller increase in VO2max in our study may be due
to the fact that not all the HVEP subjects in our study met
the exercise goal unlike the subjects in the other studies who
were completely supervised during the exercise training and
may have been more motivated because they chose to exercise.
Nonetheless even a moderate increase in VO2max is important
because physical fitness is inversely correlated with BMI (41)
and associated with a reduced risk of all cause mortality (42).
Weight loss, a secondary outcome variable, was similar
(~4.5 kg) in both groups. According to a meta-analysis includ-
ing studies that compared diet and exercise intervention
with diet only intervention in non-bariatric-surgery subjects,
weight loss was only slightly higher in the former group com-
pared to the latter group (43). Stegen et al. (39) also reported

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no difference in weight loss in the RYGB surgery patients who
chose to exercise compared to the patients who chose not to
exercise. Despite similar weight changes, the control group
in our study reported reducing their energy intake by 1.7
times as much as the HVEP group (593 kcal/day vs. 358 kcal/
day, respectively) suggesting that the latter group may have
partly compensated for the energy deficit caused by exercise
by decreasing their energy intake to a smaller extent than the
former group. Nevertheless, bariatric surgery patients who
engage in an exercise training program may be able to achieve
similar weight loss without markedly reducing their energy
intake compared to patients who are just dieting.
REE did not change significantly in either group over 12 weeks
although the decrease tended to be slightly less in the HVEP
group than in the control group. These results are probably not
explained by changes in percent body fat loss and LBM which
decreased slightly though not significantly in both groups.
Tremblay et al. (44) have also reported that REE was not modi-
fied significantly in overweight males who underwent 100 days
of endurance training despite weight loss. These results suggest
that a strategy such as exercise that helps to maintain REE may
be useful in preventing weight regain. To help preserve LBM
and thus REE, >60 g of protein intake per day is recommended
in bariatric surgery patients (24,25). Reported protein intake
was maintained at or above 60 g/day in the HVEP group but
tended to decrease to 55 g/day in the control group. Further
emphasis on increasing protein intake to help to preserve LBM
may be necessary in bariatric surgery patients.
The HVEP group also showed a reduction in the incremen-
tal area under the curve postprandial blood glucose response.
These results are corroborated by other studies (45,46), which
have reported improved postprandial blood glucose response
following 12 (ref. 45) or 20 (ref. 46) weeks of endurance train-
ing in non-bariatric-surgery obese (45) and healthy sedentary
(46) individuals.
The HVEP group tended to report greater improvement in
health-related QOL especially physical function, self-esteem,
sexual life, public distress, energy levels, and emotional and
mental well being than the control group but there was no
group-by-week interaction possibly because of the limited
sample size. According to some case series, health-related QOL
deteriorates in the long-term following bariatric surgery possi-
bly due to weight regain (47,48) whereas becoming or continu-
ing to be highly active after bariatric surgery is associated with
improved mental health–related QOL (23). A 6-month rand-
omized, controlled trial in non-bariatric-surgery overweight
or obese subjects found an improvement in all mental and
physical aspects of QOL except bodily pain following exercise
training and this relationship was exercise dose dependent and
independent of weight change (49).
A limitation of this study is that the exercise training was
implemented for only 12 weeks and in a limited number of sub-
jects. Some of the subjects who did not meet the exercise goal
felt that they needed more than 12 weeks to reach the 2,000 kcal/
week goal. A larger study with a longer duration may have pro-
vided a more comprehensive assessment of exercise feasibility.
obesity | VOLUME 19 NUMBER 9 | september 2011
articles
Bariatric Surgery
The drop-out rate was higher in the control group than in the
HVEP group because most of the subjects in the control group
would have preferred to be in the HVEP group. Future studies
should include low volume of exercise or flexibility exercises such
as yoga in the control group to improve retention rate. Another
limitation is that we did not perform a meal tolerance test in
the RYGB surgery patients given that they may experience the
dumping syndrome in response to the OGTT test. The dietary
and exercise counseling was provided at an individual level and
not at the group level. The latter format would have provided
group support. However, both groups received frequent coun-
seling from the investigators regarding their exercise and/or
dietary intervention. Lastly, we used an unsealed pedometer to
assess physical activity and the subjects logged their step count
every day during the measurement period. We do not expect
this to have affected the comparison of change in physical activ-
ity between the HVEP and control group, however, because any
reactivity to an unsealed pedometer in the HVEP group would
have also occurred in the control group. In addition, whether
an unsealed pedometer results in a different step count from a
sealed pedometer is controversial (50,51).
A major strength of this study is that it is the first rand-
omized, controlled exercise trial in bariatric surgery patients. It
is also the first study to objectively assess exercise capacity and
training effect in this population by measuring their VO2max. In
addition, both groups were also asked to improve their over-
all diet including reducing their energy intake. This is impor-
tant as bariatric surgery patients increase their energy intake
over time (11) following surgery possibly contributing to some
of the weight regain. Lastly, each subject received behavioral
therapy as discussed earlier.
In conclusion, a high-volume moderate-intensity exercise pro-
gram is feasible in about 50% of severely obese bariatric surgery
patients and improves physical fitness. It also improves postpran-
dial blood glucose response. Whether a HVEP helps to maintain
weight loss and improvement in comorbidities in these patients
remains to be evaluated in long-term studies, however. The stud-
ies also need to assess how exercise over the long term affects
factors that influence energy balance including energy intake,
nonexercise activity levels, body composition, metabolic rate,
and gastrointestinal hormones related to satiety and hunger.
Acknowledgments
We would like to acknowledge Drs Savitha Shastry, Zahid Ahmad, and
Vinaya Simha for providing clinical care to the patients during the study,
Sarah Masood for assisting with data collection, Sheena Shah-Simpson for
analyzing the food records, Rosemary Son and Drs David Provost, Nancy
Puzziferri, and Nirmal S. Jayaseelan for helping to recruit the subjects,
and Dr Joel Mitchell for consultation. The study was partly funded by NIH
grants M01-RR00633 and UL1-RR-024982 and by the Southwest Medical
Foundation.
Disclosure
The authors declared no conflict of interest.
© 2011 The Obesity Society
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