The aim of this study was to determine the effect of changes in cardiopulmonary fitness on the mental health of patients with severe obesity who underwent gastric bypass surgery (prior to and 1, 3, and 6 months after surgery). Study participants were recruited from among patients of a regional hospital in Czechia who underwent gastric bypass surgery between April 2018 and October 2019. They were eligible if they (a) were between 18 and 65 years old, (b) provided written informed consent, and (c) were able to walk independently. Twenty-six patients (age 45.4 ± 9.0 years, body mass index 45.1 ± 7.4 kg·m-2, body fat 43.8 ± 4.8%) were included in the analysis. The key finding revealed that the greater the increase in cardiopulmonary fitness (i.e., longer distance walked in the six-minute walk test, 6MWT), the better the improvement in depression score among patients who underwent bariatric surgery. In particular, increments of 10 m in the 6MWT lead to the improvement of 0.5 points on the depression subscale of the Hospital Anxiety and Depression Scale (HADS) questionnaire. As the main implication, these results suggest that patients should participate in exercise training programs to increase their fitness status for optimal physical and mental outcomes of bariatric surgery.

1st Faculty of Medicine Charles University Prague 128 00 Prague Czech Republic

2nd Department of Internal Medicine Cardiovascular Medicine General University Hospital 128 08 Prague Czech Republic

Faculty of Physical Education and Sport Charles University 162 52 Prague Czech Republic

Hospital Jablonec nad Nisou 466 01 Jablonec nad Nisou Czech Republic

Human Performance and Sports Science Laboratory Faculty of Sport Sciences University of Murcia 30720 Murcia Spain

Institute of Nursing Theory and Practice 1st Faculty of Medicine Charles University 128 00 Prague Czech Republic

See more in PubMed

Malik V.S., Willett W.C., Hu F.B. Global obesity: Trends, risk factors and policy implications. Nat. Rev. Endocrinol. 2013;9:13–27. doi: 10.1038/nrendo.2012.199. PubMed DOI

Wormser D., Kaptoge S., Di Angelantonio E., Wood A.M., Pennells L., Thompson A., Sarwar N., Kizer J.R., Lawlor D.A., Nordestgaard B.G., et al. Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: Collaborative analysis of 58 prospective studies. Lancet. 2011;377:1085–1095. PubMed PMC

Lauby-Secretan B., Scoccianti C., Loomis D., Grosse Y., Bianchini F., Straif K. Body Fatness and Cancer—Viewpoint of the IARC Working Group. N. Engl. J. Med. 2016;375:794–798. doi: 10.1056/NEJMsr1606602. PubMed DOI PMC

Hall M.E., do Carmo J.M., da Silva A.A., Juncos L.A., Wang Z., Hall J.E. Obesity, hypertension, and chronic kidney disease. Int. J. Nephrol. Renovasc. Dis. 2014;7:75–88. doi: 10.2147/IJNRD.S39739. PubMed DOI PMC

Krez A.N., Stein E.M. The Skeletal Consequences of Bariatric Surgery. Curr. Osteoporos. Rep. 2020;18:262–272. doi: 10.1007/s11914-020-00579-2. PubMed DOI

Luppino F.S., De Wit L.M., Bouvy P.F., Stijnen T., Cuijpers P., Penninx B.W.J.H., Zitman F.G. Overweight, obesity, and depression: A systematic review and meta-analysis of longitudinal studies. Arch. Gen. Psychiatry. 2010;67:220–229. doi: 10.1001/archgenpsychiatry.2010.2. PubMed DOI

The GBD 2015 Obesity Collaborators Health Effects of Overweight and Obesity in 195 Countries over 25 Years. N. Engl. J. Med. 2017;377:13–27. doi: 10.1056/NEJMoa1614362. PubMed DOI PMC

Mingrone G., Panunzi S., De Gaetano A., Guidone C., Iaconelli A., Nanni G., Castagneto M., Bornstein S., Rubino F. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 Year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015;386:964–973. doi: 10.1016/S0140-6736(15)00075-6. PubMed DOI

Courcoulas A.P., Belle S.H., Neiberg R.H., Pierson S.K., Eagleton J.K., Kalarchian M.A., De Lany J.P., Lang W., Jakicic J.M. Three-year outcomes of bariatric surgery vs lifestyle intervention for type 2 diabetes mellitus treatment a randomized clinical trial. JAMA Surg. 2015;150:931–940. doi: 10.1001/jamasurg.2015.1534. PubMed DOI PMC

Mechanick J.I., Youdim A., Jones D.B., Garvey W.T., Hurley D.L., McMahon M.M., Heinberg L.J., Kushner R., Adams T.D., Shikora S., et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by American association of clinical endocrinologists, the obesity society, and American society for metabolic & bariatric surgery. Obesity. 2013;21:S1. PubMed PMC

Gloy V.L., Briel M., Bhatt D.L., Kashyap S.R., Schauer P.R., Mingrone G., Bucher H.C., Nordmann A.J. Bariatric surgery versus non-surgical treatment for obesity: A systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:15934. doi: 10.1136/bmj.f5934. PubMed DOI PMC

O’Brien P.E. Bariatric surgery: Mechanisms, indications and outcomes. J. Gastroenterol. Hepatol. 2010;25:1358–1365. doi: 10.1111/j.1440-1746.2010.06391.x. PubMed DOI

Munoz D.J., Lal M., Chen E.Y., Mansour M., Fischer S., Roehrig M., Sanchez-Johnsen L., Dymek-Valenitine M., Alverdy J., Le Grange D. Why patients seek bariatric surgery: A qualitative and quantitative analysis of patient motivation. Obes. Surg. 2007;17:1487–1491. doi: 10.1007/s11695-008-9427-9. PubMed DOI

Maciejewski M.L., Arterburn D.E., Van Scoyoc L., Smith V.A., Yancy W.S., Weidenbacher H.J., Livingston E.H., Olsen M.K. Bariatric surgery and long-term durability of weight loss. JAMA Surg. 2016;151:1046–1055. doi: 10.1001/jamasurg.2016.2317. PubMed DOI PMC

De Zwaan M., Enderle J., Wagner S., Mühlhans B., Ditzen B., Gefeller O., Mitchell J.E., Müller A. Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using structured clinical interviews. J. Affect. Disord. 2011;133:61–68. doi: 10.1016/j.jad.2011.03.025. PubMed DOI

Gill H., Kang S., Lee Y., Rosenblat J.D., Brietzke E., Zuckerman H., McIntyre R.S. The long-term effect of bariatric surgery on depression and anxiety. J. Affect. Disord. 2019;246:886–894. doi: 10.1016/j.jad.2018.12.113. PubMed DOI

Fabricatore A.N., Sarwer D.B., Wadden T.A., Combs C.J., Krasucki J.L. Impression management or real change? Reports of depressive symptoms before and after the preoperative psychological evaluation for bariatric surgery. Obes. Surg. 2007;17:1213–1219. doi: 10.1007/s11695-007-9204-1. PubMed DOI

Wadden T.A., Sarwer D.B., Fabricatore A.N., Jones L.S., Stack R., Williams N.S. Psychosocial and Behavioral Status of Patients Undergoing Bariatric Surgery: What to Expect Before and After Surgery. Med. Clin. N. Am. 2007;91:451–469. doi: 10.1016/j.mcna.2007.01.003. PubMed DOI

Omalu B.I., Cho P., Shakir A.M., Agumadu U.H., Rozin L., Kuller L.H., Wecht C.H. Suicides following bariatric surgery for the treatment of obesity. Surg. Obes. Relat. Dis. 2005;1:447–449. doi: 10.1016/j.soard.2005.04.003. PubMed DOI

Booth H., Khan O., Prevost A.T., Reddy M., Charlton J., Gulliford M.C. Impact of bariatric surgery on clinical depression. Interrupted time series study with matched controls. J. Affect. Disord. 2015;174:644–649. doi: 10.1016/j.jad.2014.12.050. PubMed DOI

Szmulewicz A., Wanis K.N., Gripper A., Angriman F., Hawel J., Elnahas A., Alkhamesi N.A., Schlachta C.M. Mental health quality of life after bariatric surgery: A systematic review and meta-analysis of randomized clinical trials. Clin. Obes. 2019;9:e12290. doi: 10.1111/cob.12290. PubMed DOI

Kalarchian M.A., King W.C., Devlin M.J., Hinerman A., Marcus M.D., Yanovski S.Z., Mitchell J.E. Mental disorders and weight change in a prospective study of bariatric surgery patients: 7 years of follow-up. Surg. Obes. Relat. Dis. 2019;15:739–748. doi: 10.1016/j.soard.2019.01.008. PubMed DOI PMC

Moya M., Hernández A., Sarabia J.M., Sánchez-Martos M.Á., Hernández-Davó J.L., López-Grueso R., Aracil A., Pastor D., Fernández-Fernández J. Bariatric surgery, weight loss and the role of physical activity: A systematic review. Eur. J. Hum. Mov. 2014;32:145–160.

Josbeno D.A., Jakicic J.M., Hergenroeder A., Eid G.M. Physical activity and physical function changes in obese individuals after gastric bypass surgery. Surg. Obes. Relat. Dis. 2010;6:361–366. doi: 10.1016/j.soard.2008.08.003. PubMed DOI

Herring L.Y., Stevinson C., Davies M.J., Biddle S.J., Sutton C., Bowrey D., Carter P. Changes in physical activity behaviour and physical function after bariatric surgery: A systematic review and meta-analysis. Obes. Rev. 2016;17:250–261. doi: 10.1111/obr.12361. PubMed DOI

Boissière L., Perotin-Collard J.M., Bertin E., Gaubil I., Cives A.D., Barbe C., Dury S., Nardi J., Lebargy F., Deslée G., et al. Improvement of dyspnea after bariatric surgery is associated with increased Expiratory Reserve Volume: A prospective follow-up study of 45 patients. PLoS ONE. 2017;12:e0185058. PubMed PMC

Bellicha A., Ciangura C., Roda C., Torcivia A., Portero P., Oppert J.M. Changes in Cardiorespiratory Fitness After Gastric Bypass: Relations with Accelerometry-Assessed Physical Activity. Obes. Surg. 2019;29:2936–2941. doi: 10.1007/s11695-019-03932-2. PubMed DOI

Bellicha A., Ciangura C., Poitou C., Portero P., Oppert J.M. Effectiveness of exercise training after bariatric surgery—A systematic literature review and meta-analysis. Obes. Rev. 2018;19:1544–1556. doi: 10.1111/obr.12740. PubMed DOI

King W.C., Bond D.S. The importance of preoperative and postoperative physical activity counseling in bariatric surgery. Exerc. Sport Sci. Rev. 2013;41:26–35. doi: 10.1097/JES.0b013e31826444e0. PubMed DOI PMC

Ren Z.Q., Lu G.D., Zhang T.Z., Xu Q. Effect of physical exercise on weight loss and physical function following bariatric surgery: A meta-analysis of randomised controlled trials. BMJ Open. 2018;8:e023208. doi: 10.1136/bmjopen-2018-023208. PubMed DOI PMC

Hansen D., Decroix L., Devos Y., Nocca D., Cornelissen V., Dillemans B., Lannoo M. Towards Optimized Care After Bariatric Surgery by Physical Activity and Exercise Intervention: A Review. Obes. Surg. 2020;30:1118–1125. doi: 10.1007/s11695-020-04390-x. PubMed DOI

Amundsen T., Strømmen M., Martins C. Suboptimal Weight Loss and Weight Regain after Gastric Bypass Surgery—Postoperative Status of Energy Intake, Eating Behavior, Physical Activity, and Psychometrics. Obes. Surg. 2017;27:1316–1323. doi: 10.1007/s11695-016-2475-7. PubMed DOI PMC

Lawson J.L., Kerrigan S.G., Carr M.M., Wiedemann A.A., Ivezaj V., Grilo C.M. Physical activity and psychosocial correlates following bariatric surgery among patients with loss-of-control eating. Ment. Health Phys. Act. 2020;19:100343. doi: 10.1016/j.mhpa.2020.100343. DOI

David L.A., Sijercic I., Cassin S.E. Preoperative and post-operative psychosocial interventions for bariatric surgery patients: A systematic review. Obes. Rev. 2020;21:e12926. doi: 10.1111/obr.12926. PubMed DOI

Edye-mazowita A. Master’s Thesis. University of Manitoba; Winnipeg, MB, Canada: 2020. A Nonrandomized Trial of a Pre-Operative Physical Activity Program on Bariatric Surgery Candidates as Evaluated by Pre- and Post- Operative Physical Activity- and Obesity-Related Biomarkers.

In G., Taskin H.E., Al M., Alptekin H.K., Zengin K., Yumuk V., Ikitimur B. Comparison of 12-Week Fitness Protocols Following Bariatric Surgery: Aerobic Exercise Versus Aerobic Exercise and Progressive Resistance. Obes. Surg. 2021 doi: 10.1007/s11695-020-05144-5. PubMed DOI

Holland A.E., Spruit M.A., Troosters T., Puhan M.A., Pepin V., Saey D., McCormack M.C., Carlin B.W., Sciurba F.C., Pitta F., et al. An official European respiratory society/American thoracic society technical standard: Field walking tests in chronic respiratory disease. Eur. Respir. J. 2014;44:1428–1446. doi: 10.1183/09031936.00150314. PubMed DOI

Larsson U.E., Reynisdottir S. The six-minute walk test in outpatients with obesity: Reproducibility and known group validity. Physiother. Res. Int. 2008;13:84–93. doi: 10.1002/pri.398. PubMed DOI

Ekman M.J., Klintenberg M., Björck U., Norström F. Six-minute walk test before and after a weight reduction program in obese subjects. Obesity. 2013;21:E236–E243. doi: 10.1002/oby.20046. PubMed DOI

Capodaglio P., De Souza S.A., Parisio C., Precilios H., Vismara L., Cimolin V., Brunani A. Reference values for the 6-Min Walking Test in obese subjects. Disabil. Rehabil. 2013;35:1199–1203. doi: 10.3109/09638288.2012.726313. PubMed DOI

Choi L., Liu Z., Matthews C.E., Buchowski M.S. Validation of accelerometer wear and nonwear time classification algorithm. Med. Sci. Sports Exerc. 2011;43:357–364. doi: 10.1249/MSS.0b013e3181ed61a3. PubMed DOI PMC

Vetrovsky T., Clark C.C.T., Bisi M.C., Siranec M., Linhart A., Tufano J.J., Duncan M.J., Belohlavek J. Advances in accelerometry for cardiovascular patients: A systematic review with practical recommendations. ESC Heart Fail. 2020;7:2021–2031. doi: 10.1002/ehf2.12781. PubMed DOI PMC

Zigmond A.S., Snaith R.P. The hospital anxiety and depression scale. Acta Psychiatr. Scand. 1983;67:361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. PubMed DOI

Karlsson J., Taft C., Rydén A., Sjöström L., Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: The SOS intervention study. Int. J. Obes. 2007;31:1248–1261. doi: 10.1038/sj.ijo.0803573. PubMed DOI

Beiza B.L., Henke C.J., Yeun E., Epstein W.V., Gauss C.I. Correlates of fatigue in older adults with rheumatoid arthritis. Nurs. Res. 1993;42:93–99. PubMed

Belza B., Miyawaki C.E., Liu M., Aree-Ue S., Fessel M., Minott K.R., Zhang X. A Systematic review of studies using the multidimensional assessment of fatigue scale. J. Nurs. Meas. 2018;26:36–75. doi: 10.1891/1061-3749.26.1.36. PubMed DOI

Gaillard T.R., Sherman W.M., Devor S.T., Kirby T.E., Osei K. Importance of aerobic fitness in cardiovascular risks in sedentary overweight and obese African-American women. Nurs. Res. 2007;56:407–415. doi: 10.1097/01.NNR.0000299851.67676.34. PubMed DOI

Ware J.E., Sherbourne C.D. The MOS 36-item short-form health survey (Sf-36): I. conceptual framework and item selection. Med. Care. 1992;30:473–483. doi: 10.1097/00005650-199206000-00002. PubMed DOI

Lemay K.R., Tulloch H.E., Pipe A.L., Reed J.L. Establishing the Minimal Clinically Important Difference for the Hospital Anxiety and Depression Scale in Patients with Cardiovascular Disease. J. Cardiopulm. Rehab. Prev. 2019;39:E6–E11. doi: 10.1097/HCR.0000000000000379. PubMed DOI

Puhan M.A., Frey M., Büchi S., Schünemann H.J. The Minimal Important Difference of the Hospital Anxiety and Depression Scale in Patients with Chronic Obstructive Pulmonary Disease. Health Qual. Life Outcomes. 2008;6:46. doi: 10.1186/1477-7525-6-46. PubMed DOI PMC

Neovius M., Bruze G., Jacobson P., Sjöholm K., Johansson K., Granath F., Sundström J., Näslund I., Marcus C., Ottosson J., et al. Risk of suicide and non-fatal self-harm after bariatric surgery: Results from two matched cohort studies. Lancet Diabetes Endocrinol. 2018;6:197–207. doi: 10.1016/S2213-8587(17)30437-0. PubMed DOI PMC

Vetrovsky T., Cupka J., Dudek M., Kuthanova B., Vetrovska K., Capek V., Bunc V. Mental health and quality of life benefits of a pedometer-based walking intervention delivered in a primary care setting. Acta Gymnica. 2017;47:138–143. doi: 10.5507/ag.2017.017. DOI

Jassil F.C., Manning S., Lewis N., Steinmo S., Kingett H., Lough F., Pucci A.B.F., Cheung W.H., Finer N., Walker J., et al. Feasibility and Impact of a Combined Supervised Exercise and Nutritional-Behavioral Intervention following Bariatric Surgery: A Pilot Study. J. Obes. 2015;2015 doi: 10.1155/2015/693829. PubMed DOI PMC

Petridou A., Siopi A., Mougios V. Exercise in the management of obesity. Metabolism. 2019;92:163–169. doi: 10.1016/j.metabol.2018.10.009. PubMed DOI

de Souza S.A.F., Faintuch J., Fabris S.M., Nampo F.K., Luz C., Fabio T.L., Sitta I.S., de Batista Fonseca I.C. Six-minute walk test: Functional capacity of severely obese before and after bariatric surgery. Surg. Obes. Relat. Dis. 2009;5:540–543. doi: 10.1016/j.soard.2009.05.003. PubMed DOI

Possmark S., Sellberg F., Willmer M., Tynelius P., Persson M., Berglind D. Accelerometer-measured versus self-reported physical activity levels in women before and up to 48 months after Roux-en-Y Gastric Bypass. BMC Surg. 2020;20:1–10. doi: 10.1186/s12893-020-00699-7. PubMed DOI PMC

Ekkekakis P., Parfitt G., Petruzzello S.J. The pleasure and displeasure people feel when they exercise at different intensities: Decennial update and progress towards a tripartite rationale for exercise intensity prescription. Sport Med. 2011;41:641–671. doi: 10.2165/11590680-000000000-00000. PubMed DOI

Courel-Ibáñez J., Martínez-Cava A., Morán-Navarro R., Escribano-Peñas P., Chavarren-Cabrero J., González-Badillo J.J., Pallarés J.G. Reproducibility and Repeatability of Five Different Technologies for Bar Velocity Measurement in Resistance Training. Ann. Biomed. Eng. 2019;47:1523–1538. doi: 10.1007/s10439-019-02265-6. PubMed DOI

Courel-Ibáñez J., Pallarés J.G., García-Conesa S., Buendía-Romero Á., Martínez-Cava A., Izquierdo M. Supervised Exercise (Vivifrail) Protects Institutionalized Older Adults Against Severe Functional Decline After 14 Weeks of COVID Confinement. J. Am. Med. Dir. Assoc. 2021;22:217–219.e2. doi: 10.1016/j.jamda.2020.11.007. PubMed DOI PMC

Khushhal A., Nichols S., Carroll S., Abt G., Ingle L. Characterising the application of the “progressive overload” principle of exercise training within cardiac rehabilitation: A United Kingdom-based community programme. PLoS ONE. 2020;15:e0237197. doi: 10.1371/journal.pone.0237197. PubMed DOI PMC

Khushhal A., Nichols S., Carroll S., Abt G., Ingle L. Insufficient exercise intensity for clinical benefit? Monitoring and quantification of a community-based Phase III cardiac rehabilitation programme: A United Kingdom perspective. PLoS ONE. 2019;14:e0217654. doi: 10.1371/journal.pone.0217654. PubMed DOI PMC