**4.2 Rehabilitation**

## *4.2.1 Physical activity and exercise*

Surgery-induced weight loss by itself was associated with a series of beneficial health effects, including increased objectively measured habitual physical activity and cardiorespiratory fitness [29]. Using a cardiac rehabilitation model is effective to cause significant improvement in bariatric individuals' cardio-metabolic profile [31]. Hanapi et al. demonstrates the application of cardiac rehabilitation principle for post-bariatric surgery patients which include risk stratification through the use of submaximal exercise stress testing to objectively quantify the patient's cardiovascular capacity for exercise participation, subsequent exercise prescription based on the individuals' physical impairments and cardiovascular functioning, lifestyle modification to manage cardiovascular risk factors and translating the gains of cardiorespiratory and musculoskeletal fitness into more functional activities [9].

Postoperative exercise is imperative and remains the most important factor that can help a patient achieve long-standing and successful weight loss. Exercises can begin as early as day one postoperatively and short term and long term goals should be set early on and revised as activity and exercise capacity increases. The exercise program should incorporate muscle strengthening, physical endurance or aerobic exercises to improve cardiorespiratory fitness, balance training, functional mobility, musculoskeletal reconditioning, joint protection as well activity of daily living (ADL) training, tailored individually within the limit of patients' cardiovascular capacity.

To sustain weight loss, effective behaviour changes towards increasing energy expenditure through occupational, leisure time and planned physical activity needs to occur alongside dietary management [32]. Physical activity can be incorporated to daily activities which helps with caloric expenditure or decreasing the amount of sitting time or sedentary leisure activities. Education on the importance of physical activities to aid weight loss and maintain functional independence helps boost motivation and compliance. This ultimately affects their level of independence, quality of life and self-efficacy [9].

In addition to loss of fat mass, there are other numerous benefits to exercise. These benefits include prevention of loss of muscle mass when losing weight rapidly after surgery, and improved overall weight loss. Exercise may also reduce a person's appetite, increases immunity and reduces fatigue which may lead to improved selfconfidence, and overall improved sense of well-being.

#### *4.2.2 Psychosocial*

A substantial number of patients experience poor long-term outcomes following bariatric surgery which may be contributed by difficulty in making and sustaining changes in dietary intake and physical activity as well as post-surgery binge eating, which has also been associated with poorer weight outcomes [33]. A thorough preoperative assessment to evaluate patients' understanding of the disease condition, identifying any misconceptions, assessing readiness and commitment to undergo

a radical change in lifestyle and behaviour modification, as well identifying issues that may pose as barriers may be the key to a successful and sustainable weight management postoperatively. Sheets et al. recommend that preoperative assessment should include identifying patients strengths and weaknesses, educating patients thoroughly about postoperative changes including dietary intake and physical activity, coaching on lifestyle change strategies as well as offering specific recommendations to address any areas of concern [34]. The period post bariatric surgery is still a vulnerable time for most individuals as the reality sinks in as adjustment of behaviours and new habits take place. The need for continuous care and screening of psychosocial issues throughout both pre-and postoperative periods cannot be undermined. Screening for aberrant eating behaviours and depressive symptoms should be assessed whilst administering interventions to address emotional and psychological issues, behavioural modification strategies, increase compliance, and provide support [34]. It is the responsibility of each team member to detect or identify the presence of any psychological issues, and administer interventions through early referral to mental health professionals to improve outcomes of these individuals.
