In the evolving landscape of obesity treatment, bariatric surgery stands as one of the most effective interventions for individuals grappling with severe obesity. While this surgical approach can dramatically alter physical health trajectories, the journey to success is far from straightforward. Emerging research underscores the crucial role of pre-surgical rehabilitation, particularly in addressing the psychological and behavioral complexities that influence long-term outcomes. A recent comprehensive scoping review sheds new light on the psychological determinants shaping exercise adherence among patients awaiting bariatric surgery and explores innovative physical therapy strategies that could revolutionize prehabilitation programs.
Bariatric surgery, despite its demonstrable efficacy in promoting weight loss and ameliorating obesity-related comorbidities, is not a silver bullet. Patients embarking on this surgical path often encounter multifaceted challenges that span from psychological barriers to behavioral inconsistencies, which can undermine the surgery’s benefits if left unaddressed. Among these hurdles, exercise adherence emerges as a critical factor, intricately linked with both physical recovery and sustainable weight management. The scoping review meticulously delves into modifiable psychological processes—those cognitive and emotional variables amenable to intervention—that potentially determine how consistently patients engage with prescribed physical activity regimens.
A standout aspect of the review is its methodological rigor, following the JBI (Joanna Briggs Institute) protocol to ensure a systematic and exhaustive examination of the literature. Researchers assessed a wide range of databases, encompassing EMBASE, Scopus, Web of Science, PubMed, Cochrane Library, Physiotherapy Evidence Database (PEDro), PsycINFO, LILACS, and even grey literature sources such as Google Scholar. This breadth of inquiry allowed for a rich and nuanced synthesis of findings from diverse populations and clinical contexts. The studies analyzed targeted adults of both sexes with obesity, all of whom were enrolled in perioperative intervention programs—a critical period where behavioral modifications can yield outsized benefits.
From this rigorous review, seven studies were identified that directly address the psychological contributors to exercise adherence in bariatric surgery candidates. These psychological elements were distilled into several core constructs: quality of life, pleasure derived from exercise, intrinsic motivation, self-efficacy beliefs, self-monitoring practices, goal-setting behaviors, and proactive information seeking. Each of these factors interacts in complex ways to either promote or hinder the patient’s commitment to physical activity during the preoperative phase. For instance, individuals who perceive exercise as pleasurable or rewarding tend to exhibit better adherence, highlighting the importance of fostering positive affective experiences within rehabilitation programs.
Motivation and self-efficacy—the belief in one’s capacity to execute specific behaviors—emerge as particularly salient drivers of exercise engagement. These constructs are rooted in well-established psychological theories such as Self-Determination Theory and Social Cognitive Theory, which emphasize autonomy, competence, and relatedness as key motivators for sustained behavior change. Interventions that enhance patients’ confidence in their ability to perform physical activity, and that help them internalize the value of exercise beyond mere obligation, are crucial for long-term adherence. The review suggests a paradigm shift from prescriptive exercise protocols toward empowering, patient-centered counseling.
Cognitive-behavioral therapy (CBT) surfaced as an effective intervention modality within the reviewed studies. By addressing maladaptive thoughts, enhancing problem-solving skills, and reducing exercise-related anxieties, CBT helps individuals overcome common psychological barriers to activity. This therapeutic approach can be delivered in both individual and group formats, leveraging social support mechanisms while tailoring strategies to individual challenges. Moreover, the inclusion of motivational interviewing techniques complements CBT by fostering patient ambivalence resolution and strengthening commitment to change.
Another innovative dimension explored in these studies involves the deployment of digital technologies to optimize exercise adherence. Remote and digital platforms offer promising avenues for delivering real-time feedback, self-monitoring tools, and interactive goal-setting features. Mobile apps, wearable devices, and telehealth services can extend the reach of physical therapy support beyond clinical settings, providing continuous encouragement and accountability. The integration of these technologies within prehabilitation programs aligns with the growing movement toward personalized medicine and patient empowerment, offering scalable solutions that transcend geographic and socioeconomic barriers.
While the psychological determinants identified are critical, the review emphasizes that successful prehabilitation programs must adopt a multi-theoretical approach. This necessitates the amalgamation of various behavioral and psychological frameworks to address the spectrum of factors influencing exercise adherence. Tailoring interventions to the unique needs, preferences, and psychosocial contexts of surgical candidates ensures higher relevance and engagement. Such customization also accounts for demographic variables such as age, sex, cultural background, and baseline fitness, which modulate patients’ responses to therapeutic strategies.
The notion of quality of life as a motivating factor warrants special attention, as it encapsulates both physical and psychological well-being. Patients who experience improvements in mood, energy levels, and social functioning as a result of exercise are more likely to maintain these behaviors. Therefore, rehabilitation efforts should not solely prioritize physical metrics but also assess and enhance subjective quality of life indices. Encouragingly, some studies document increases in enjoyment and pleasure derived from physical activity, suggesting that redesigning exercise prescriptions to maximize these positive experiences could be a game changer in preoperative care.
Goal setting and self-monitoring are integral behavioral techniques that empower patients to take ownership of their activity patterns. By establishing clear, attainable objectives and systematically tracking progress, patients cultivate a sense of achievement and control. These processes also generate vital data that clinicians can use to tailor interventions responsively. Digital platforms are particularly adept at facilitating these activities, offering user-friendly interfaces for logging exercise sessions, setting reminders, and analyzing trends over time.
Information seeking emerges as another psychological variable with notable implications. Patients actively engaged in gathering knowledge about the benefits of exercise, surgical outcomes, and rehabilitation protocols tend to demonstrate higher adherence. This underscores the importance of educational components within prehabilitation programs, where providing transparent, evidence-based information can dispel misconceptions and reduce anxiety surrounding surgery and physical activity.
An overarching theme in the review is the necessity of embedding physical activity counseling within a holistic rehabilitation framework. Physical therapists, equipped with knowledge of psychological determinants, are optimally positioned to lead these multidisciplinary efforts. Their expertise in exercise prescription, combined with counseling skills and familiarity with behavioral change techniques, positions them as pivotal agents in enhancing pre-surgical fitness and psychological readiness.
Finally, the adoption of remote digital technologies preoperatively is increasingly viewed as not only feasible but essential in modern healthcare delivery. These modalities can reduce barriers related to distance, time constraints, and mobility limitations that often restrict patient participation in traditional rehabilitation programs. Moreover, by complementing face-to-face interactions with sustained virtual support, they foster continuity of care and facilitate the maintenance of behavioral gains.
In summary, the scoping review illuminates the intricate interplay of psychological determinants that influence exercise adherence among individuals preparing for bariatric surgery. By embracing multi-faceted and theory-driven interventions—ranging from cognitive-behavioral therapies and motivational counseling to digital health innovations—physical therapy prehabilitation programs can profoundly enhance treatment efficacy. As obesity rates continue to climb globally, refining these approaches will be crucial in optimizing surgical outcomes and fostering sustainable health improvements.
Subject of Research: Psychological determinants of exercise adherence in individuals with severe obesity awaiting bariatric surgery and physical therapy intervention strategies in prehabilitation programs.
Article Title: Psychological determinants of exercise adherence in individuals with severe obesity awaiting bariatric surgery: what strategies can physical therapists adopt in prehabilitation programs? A scoping review.
Article References:
Nascimento, A.Q., Matte, D.L., Dantas, D.B. et al. Psychological determinants of exercise adherence in individuals with severe obesity awaiting bariatric surgery: what strategies can physical therapists adopt in prehabilitation programs? A scoping review. Int J Obes (2025). https://doi.org/10.1038/s41366-025-01830-5
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