The Impact of Vitamin D, Calcium, Protein Supplementation, and Physical Exercise on Bone Metabolism After Bariatric Surgery: The BABS Study

Effect of a high-impact exercise program on hip strength indices in a group of obese women after bariatric surgery

The purpose of this study was to explore the influence of a 12-month high-impact physical training program (descending stairs) on bone health in a group of young obese women who had undergone bariatric surgery (type sleeve). Fifty-two premenopausal women with a body mass index (BMI) > 35 kg/m2 (range: 35.06-60.97 kg/m2), aged 19-47 years old were included in this study. Patients were randomized to either exercise group (EG), control group (CG) or observational group (OG). 2 to 3 weeks post-bariatric surgery (BS), EG underwent a 12-month semi-supervised high impact (descending stairs) exercise program, CG performed a 12-month oriental dance activity while the third OG received only standard medical care. Patients were assessed before BS and 12 months post-BS for body composition, bone mineral density (BMD) and femoral neck geometry. Bone parameters were evaluated by DXA. At baseline, there were no significant differences among the three groups in the clinical characteristics and the bone variables. 12 months after the surgery, there were some group*time interactions. The 3 groups showed significantly lower whole body BMD (-1.8; -2.9; -4.2 % respectively for EG; CG and OG). The EG showed a significant increase of the femoral neck BMD (+1.4 %; p < 0.05), the femoral neck cross-sectional area (+4.6 %; p < 0.05), and the femoral neck cross-sectional moment of inertia (+15.7 %; p < 0.01) while all these values decreased significantly in the 2 other groups. The total hip BMD decreased in all groups, but the EG showed less significant total hip variation, and lumbar spine BMD decreased significantly only in the OG. This study mainly shows that the stair descent can be considered as an effective high-impact physical exercise for obese women who have undergone bariatric surgery. This kind of exercise has significant effects in maintaining or reducing the loss of BMD at the femoral neck and the total hip. Finally, since the EG group showed significant increases in femoral neck geometry variables, this study suggests that this kind of training could be efficient at reducing the hip fracture risk.

Obesity and Metabolic Disease Impair the Anabolic Response to Protein Supplementation and Resistance Exercise: A Retrospective Analysis of a Randomized Clinical Trial with Implications for Aging, Sarcopenic Obesity, and Weight Management

BACKGROUND

Anabolic resistance accelerates muscle loss in aging and obesity, thus predisposing to sarcopenic obesity.

METHODS

In this retrospective analysis of a randomized clinical trial, we examined baseline predictors of the adaptive response to three months of home-based resistance exercise, daily physical activity, and protein-based, multi-ingredient supplementation (MIS) in a cohort of free-living, older males (n = 32).

RESULTS

Multiple linear regression analyses revealed that obesity and a Global Risk Index for metabolic syndrome (MetS) were the strongest predictors of Δ% gains in lean mass (TLM and ASM), LM/body fat ratios (TLM/%BF, ASM/FM, and ASM/%BF), and allometric LM (ASMI, TLM/BW, TLM/BMI, ASM/BW), with moderately strong, negative correlations to the adaptive response to polytherapy r = -0.36 to -0.68 (p < 0.05). Kidney function, PA level, and chronological age were only weakly associated with treatment outcomes (p > 0.05). Next, we performed a subgroup analysis in overweight/obese participants with at least one other MetS risk factor and examined their adaptive response to polytherapy with two types of protein-based MIS (PLA; collagen peptides and safflower oil, n = 8, M5; whey/casein, creatine, calcium, vitamin D3, and fish oil, n = 12). The M5 group showed greater improvements in LM (ASM; +2% vs. -0.8%), LM/body fat ratios (ASM/FM; +3.8% vs. -5.1%), allometric LM (ASM/BMI; +1.2% vs. -2.5%), strength (leg press; +17% vs. -1.4%), and performance (4-Step-Stair-Climb time; -10.5% vs. +1.1%) vs. the PLA group (p < 0.05). Bone turnover markers, indicative of bone accretion, were increased pre-to-post intervention in the M5 group only (P1NP; p = 0.036, P1NP/CTX ratio; p = 0.088). The overall anabolic response, as indicated by ranking low-to-high responders for Δ% LM (p = 0.0079), strength (p = 0.097), and performance (p = 0.19), was therefore significantly higher in the M5 vs. PLA group (p = 0.013).

CONCLUSIONS

Our findings confirm that obesity/MetS is a key driver of anabolic resistance in old age and that a high-quality, whey/casein-based MIS is more effective than a collagen-based alternative for maintaining musculoskeletal health in individuals at risk for sarcopenic obesity, even when total daily protein intake exceeds current treatment guidelines.

Expert-based physical activity guidelines for metabolic and bariatric surgery patients: a systematic review of randomized controlled trials

Patients undergoing metabolic and bariatric surgery (MBS) can improve outcomes through a physically active lifestyle. Despite ongoing research, clinical recommendations for physical activity (PA) are not fully developed. For this review, 39 articles representing 24 randomized clinical trials satisfied inclusion criteria. The PA interventions utilized in these trials, the expertise of the multidisciplinary research team, and the general principles of strength and conditioning were considered in the creation of the following 12 PA recommendations: 1) Begin PA intervention pre-MBS; 2) Unless contraindicated, walk short distances the day of the surgery; 3) Progressively increase movement through activities of daily living during the first month postoperatively; 4) Avoid prolonged sitting and adopt lifestyle routines that decrease sedentary time; 5) Slowly progress to 150-300 minutes of accumulated moderate-intensity cardiovascular exercise/week; 6) In addition to walking, gradually increase structured PA through a variety of activities; 7) Delay water exercise until surgical wounds have healed, around 4 weeks postoperatively; 8) Begin full body resistance training (RT) 4-6 weeks post-MBS on 2 noncontinuous d/wk; 9) Delay high-intensity PA and abdominal exercises for 8-12 weeks; 10) Have periodic assessments of strength and cardiovascular fitness to evaluate progress; 11) Continue long-term monitoring with exercise professionals in the context of health; and 12) Consult with a registered dietitian to optimize nutrition alongside changes in PA.

Research on DXA bone density measurements and trabecular bone scores in Chinese men and women with obesity before and after bariatric surgery

OBJECTIVE

Dual energy X-ray absorptiometry (DXA) was used to analyze body composition, bone mineral density (BMD) parameters and the trabecular bone score (TBS) in patients with obesity before, 3 months after and 1 year after bariatric surgery as a method to evaluate the changes in BMD and skeletal microarchitecture (MA) in patients with obesity after bariatric surgery and to provide a basis for further accurate assessment of the bone health status of this population and subsequent treatment.

METHODS

This study was a retrospective analysis of 41 patients that underwent DXA imaging before, 3 months after and maximum 1 year after bariatric surgery. The follow-up rate in both periods was 100%. First, the changes in BMD and TBS before and after surgery were compared between patients grouped by sex and obesity degree. Secondly, the correlations between the TBS or BMD and body composition 1 year after surgery were analyzed.

RESULTS

The BMD and TBS were within the normal range after bariatric surgery. Changes in the BMD and TBS were related to time, the degree of obesity and sex. Changes in the TBS were closely related to changes in the BMD, and the trends in the changes in the BMD were basically the same among the different groups of individuals with obesity of different sexes. A negative correlation was observed between the TBS and fat percentage (total body, leg, trunk, android area), as well as the lumbar spine Z-score in patients 1 year after bariatric surgery (p < 0.05).

CONCLUSIONS

Bariatric surgery in patients with obesity has no obvious adverse effects on BMD or TBS. DXA can be used to better evaluate the changes in BMD and MA in patients with obesity after bariatric surgery, providing a basis for the clinical evaluation of post-bariatric surgery efficacy in these individuals and subsequent accurate assessment of the bone health status and treatment of this population.

SICOB Italian clinical practice guidelines for the surgical treatment of obesity and associated diseases using GRADE methodology on bariatric and metabolic surgery

Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m2), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures.

Bone loss after bariatric surgery is observed mainly in the hip trabecular compartment and after hypoabsorptive techniques

We evaluated the impact of bariatric surgery on bone mineral density (BMD) and microarchitecture over one year using dual-energy X-ray absorptiometry (DXA), the trabecular bone score (TBS), and 3D-DXA to assess changes after different surgical techniques. This prospective, single-center study of 153 patients with severe obesity contrasts the effects on bone health of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch/single anastomosis duodeno-ileostomy with sleeve gastrectomy (DS/SADIS). To our knowledge, this is the first study to evaluate patients undergoing DS/SADIS and to incorporate 3D-DXA analysis in the assessment of bone loss. Patients were 81 % female with a mean age of 50 ± 9 years. Fifty-four per cent underwent SG; 16 %, RYGB; and 30 %, DS/SADIS. Our findings revealed a significant decrease in areal BMD at the LS (-3.49 ± 5.44 %), FN (-5.24 ± 5.86 %), and TH (-8.06 ± 5.14 %) one year after bariatric surgery. Bone microarchitecture at the LS assessed by TBS was degraded in 30 % of patients. Proximal femur 3D-DXA analysis showed that surgery-induced bone loss predominantly affects the trabecular compartment (Trabecular volumetric (v) BMD: -8.00 ± 6.57 %) rather than the cortical compartment (Cortical vBMD: -1.37 ± 2.79 %). These results suggest hypoabsorptive and mixed techniques (DS/SADIS and RYGB) were associated with greater BMD loss and deterioration of microarchitecture than restrictive techniques (SG). The primary determinants of bone density and impairment of microarchitecture were the extent of weight loss and the type of surgical procedure. Despite overall bone loss, Z-score assessments indicated that post-surgical bone status remained within or above the average ranges compared to a healthy population, except for TH following DS/SADIS. In conclusion, our research shows differences in the impact of bariatric surgery techniques on bone density and microarchitecture, emphasizing the need for careful postoperative monitoring of bone health, particularly in patients undergoing hypoabsorptive and mixed procedures.

Oral vitamin D supplementation for adults with obesity undergoing bariatric surgery

BACKGROUND

Vitamin D deficiency following bariatric surgery is common and is expected to be associated with a deleterious impact on the skeleton. However, the benefits of vitamin D supplementation and the optimal dose in this population is currently unknown. The available guidelines on the topic are derived from experts' opinions, and are not evidence based.

OBJECTIVES

To compare the effects of different doses of vitamin D supplementation (low dose (less than 600 international units (IU)/day), moderate dose (600 IU/day to 3500 IU/day), high dose (greater than 3500 IU/day)) to each other or to placebo in adults living with obesity undergoing bariatric surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, two trial registries, and the reference lists of systematic reviews, articles, and health technology assessment reports without language restrictions. The last search of all databases was 27 June 2023, except Embase, which we searched on 14 August 2015.

SELECTION CRITERIA

We included randomised controlled trials or controlled clinical trials on vitamin D supplementation comparing different doses or comparing vitamin D to placebo in people undergoing bariatric surgery.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were fractures and adverse events. Secondary outcomes were vitamin D status, all-cause mortality, bone mineral change, secondary hyperparathyroidism, health-related quality of life, and muscle strength. We used GRADE to assess the certainty of the evidence for each outcome in each comparison.

MAIN RESULTS

We identified five trials with 314 participants. We included three trials in the quantitative analysis. Moderate-dose vitamin D compared to placebo One trial compared moderate-dose vitamin D (3200 IU/day) to placebo. Moderate-dose vitamin D, compared to placebo, may improve vitamin D status and may result in little to no difference in the achieved parathyroid hormone level (achieved 25-hydroxyvitamin D level: mean difference (MD) 13.60 ng/mL, 95% confidence interval (CI) 7.94 to 19.26; achieved parathyroid hormone level: -6.60 pg/mL, 95% CI -17.12 to 3.92; 1 study, 79 participants; low-certainty evidence). The trial reported no adverse events in the moderate-dose vitamin D arm, but did not provide any information on adverse events in the placebo arm. There were no data on fractures, all-cause mortality, bone density change, health-related quality of life, and muscle strength. High-dose vitamin D compared to moderate-dose vitamin D Two trials in Roux-en-Y gastric bypass compared moderate-dose (equivalent dose 800 IU/day to 2000 IU/day) to high-dose (equivalent dose 5000 IU/day to 7943 IU/day) vitamin D. The evidence of high-dose vitamin D on adverse events is very uncertain (risk ratio (RR) 5.18, 95% CI 0.23 to 116.56; 2 studies, 81 participants; very low-certainty evidence). High-dose vitamin D may increase 25-hydroxyvitamin D levels compared to a moderate dose at 12 months, but the evidence is very uncertain (MD 15.55 ng/mL, 95% CI 3.50 to 27.61; I2 = 62%; 2 studies, 73 participants; very low-certainty evidence). High-dose vitamin D may have little to no effect on parathyroid hormone levels compared to a moderate dose at 12 months, but the evidence is very uncertain (MD 2.15 pg/mL, 95% CI -21.31 to 17.01; I2 = 0%; 2 studies, 72 participants; very low-certainty evidence). High-dose vitamin D may have little to no effect on mortality and bone mineral density at the lumbar spine, hip, and forearm, but the evidence is very uncertain. There were no data on fractures, health-related quality of life, or muscle strength.

AUTHORS' CONCLUSIONS

No trials reported on fractures and the evidence available on adverse events is scarce. Moderate-dose vitamin D may improve vitamin D status and may result in little to no improvement in parathyroid hormone levels compared with placebo. High-dose vitamin D supplementation (greater than 3500 IU/day) may increase 25-hydroxyvitamin D levels, and may have little to no effect on parathyroid hormone levels, compared to a moderate dose, but the evidence for both is very uncertain. The currently available limited evidence may not have a significant impact on practice. Further studies are needed to explore the impact of vitamin D supplementation on fractures, adverse events, and musculoskeletal parameters in people undergoing bariatric surgery.

Bone health in adults with obesity before and after interventions to promote weight loss

Obesity and its associated comorbidities constitute a serious and growing public health burden. Fractures affect a substantial proportion of people with obesity and result from reduced bone strength relative to increased mechanical loading, together with an increased risk of falls. Factors contributing to fractures in people with obesity include adverse effects of adipose tissue on bone and muscle and, in many people, the coexistence of type 2 diabetes. Strategies to reduce weight include calorie-restricted diets, exercise, bariatric surgery, and pharmacological interventions with GLP-1 receptor agonists. However, although weight loss in people with obesity has many health benefits, it can also have adverse skeletal effects, with increased bone loss and fracture risk. Priorities for future research include the development of effective approaches to reduce fracture risk in people with obesity and the investigation of the effects of GLP-1 receptor agonists on bone loss resulting from weight reduction.

Preoperative Micronutrient Repletion Strategies in Metabolic and Bariatric Surgery: A Systematic Review

BACKGROUND

Evidence is lacking to inform how micronutrient deficiencies should be prevented and treated before metabolic-bariatric surgery to optimize patient outcomes.

OBJECTIVE

This systematic review aimed to examine the effect of preoperative repletion strategies for micronutrient deficiencies on micronutrient biochemistry, quality of life, and complication rates among candidates for metabolic and bariatric surgery compared with usual care, alternate strategies, or no treatment.

METHODS

PubMed, Embase, CINAHL, and CENTRAL was searched in April 2024. A grey literature search was updated in April 2024 via Google search. Eligible observational and interventional studies were those that provided micronutrient repletion before the surgery and measured micronutrient status pre- and/or postsurgery. Studies with participants who were pregnant, lactating, or elected jejunocolic bypass, jejunoileal bypass, vertical banded gastroplasty, and biliopancreatic diversion were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics Quality Criteria Checklist. Findings were narratively synthesized and the Grading of Recommendation, Assessment, Development and Evaluations was adopted when applicable. Twenty studies (n = 27 groups) were included (n = 15 observational; n = 5 interventional).

RESULTS

Strategies targeted vitamins A, D, E, B6, B12, C, thiamin, folate, calcium, iron, selenium, and zinc, including chronic dosing of oral supplements and multivitamins (n = 21), megadoses of oral supplements (n = 1), intramuscular injection (n = 1), intravenous infusion (n = 1), and a mix of injection and oral supplements (n = 3). Preoperative repletion strategies varied in efficacy. Chronic dosing of oral supplements increased vitamin D levels (n = 4 interventional studies; Grading of Recommendation, Assessment, Development and Evaluations rating: moderate). Multivitamins did not improve vitamin B12 status but improved status of vitamin B6, vitamin C, and folate. Iron infusion (n = 1) increased ferritin levels, despite small sample size and low adherence rate, whereas oral iron supplementation resulted in unchanged (n = 4) or decreased (n = 1) ferritin levels.

CONCLUSIONS

Proactive and personalized micronutrient repletion schedules may decrease the risk of preoperative and early postoperative deficiency.

No Increased Risk of All-cause Revision up to 10 Years in Patients Who Underwent Bariatric Surgery Before Single-level Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study aimed to assess whether prior bariatric surgery (BS) is associated with higher 10-year surgical complication and revision rates in lumbar spine fusion compared with the general population and morbidly obese patients.

BACKGROUND

Obesity accelerates degenerative spine processes, often necessitating lumbar fusion for functional improvement. BS is explored for weight loss in lumbar spine cases, but its impact on fusion outcomes remains unclear. Existing literature on BS before lumbar fusion yields conflicting results, with a limited investigation into long-term spine complications.

METHODS

Utilizing the PearlDiver database, we examined patients undergoing elective primary single-level lumbar fusion, categorizing them by prior BS. Propensity score matching created cohorts from (1) the general population without BS history and (2) morbidly obese patients without BS history. Using Kaplan-Meier and Cox proportional hazard modeling, we compared 10-year cumulative incidence rates and hazard ratios (HRs) for all-cause revision and specific revision indications.

RESULTS

Patients who underwent BS exhibited a higher cumulative incidence and risk of decompressive laminectomy and irrigation & debridement (I&D) within 10 years postlumbar fusion compared with matched controls from the general population [decompressive laminectomy: HR = 1.32; I&D: HR = 1.35]. Compared with matched controls from a morbidly obese population, patients who underwent BS were associated with lower rates of adjacent segment disease (HR = 0.31) and I&D (HR = 0.64). However, the risk of all-cause revision within 10 years did not increase for patients who underwent BS compared with matched or unmatched controls from the general population or morbidly obese patients (P > 0.05).

CONCLUSIONS

Prior BS did not elevate the 10-year all-cause revision risk in lumbar fusion compared with the general population or morbidly obese patients. However, patients who underwent BS were associated with a lower 10-year risk of I&D when compared with morbidly obese patients without BS. Our study indicates comparable long-term surgical complication rates between patients who underwent BS and these control groups, with an associated reduction in risk of infectious complications when compared with morbidly obese patients. Although BS may address medical comorbidities, its impact on long-term lumbar fusion revision outcomes is limited.

Medication and supplement pharmacokinetic changes following bariatric surgery: A systematic review and meta-analysis

OBJECTIVES

To evaluate the impact of bariatric surgery on the pharmacokinetic (PK) parameters of orally administered medications and supplements.

METHODS

Systematic searches of bibliographic databases were conducted to identify studies. Pooled effect estimates from different surgical procedures were calculated using a random-effects model.

RESULTS

Quantitative data were synthesized from 58 studies including a total of 1985 participants. Whilst 40 medications and 6 supplements were evaluated across these studies, heterogeneity and missing information reduced the scope of the meta-analysis to the following medications and supplements: atorvastatin, paracetamol, omeprazole, midazolam, vitamin D, calcium, zinc, and iron supplements. There were no significant differences in PK parameters post-surgery for the drugs atorvastatin and omeprazole, and supplements calcium, ferritin, and zinc supplements. Paracetamol showed reduced clearance (mean difference [MD] = -15.56 L/hr, p = 0.0002, I2 = 67%), increased maximal concentration (MD = 6.90 μg/ml, p = 0.006, I2 = 92%) and increased terminal elimination half-life (MD = 0.49 hr, p < 0.0001, I2 = 3%) post-surgery. The remaining 36 medications and 2 supplements were included in a systematic review. Overall, 18 of the 53 drugs and supplements showed post-operative changes in PK parameters.

CONCLUSION

This study demonstrates heterogeneity in practice and could not reach conclusive findings for most PK parameters. Prospective studies are needed to inform best practice and enhance patient healthcare and safety following bariatric surgery.

Exercise interventions following bariatric surgery are poorly reported: A systematic review and a call for action

OBJECTIVES

This study assessed the transparency and replicability of exercise-based interventions following bariatric surgery by evaluating the content reporting of exercise-based clinical trials.

DESIGN

The study design of the present article is a systematic review.

DATA SOURCES

PubMed, Scopus, Web of Sciences, PsycINFO, and Cochrane were searched from their inception to May 2023.

ELIGIBILITY CRITERIA

Eligible studies were clinical trials including exercise interventions in participants following bariatric surgery. There were 28 unique exercise interventions. Two independent reviewers applied the exercise prescription components of Frequency, Intensity, Time, and Type (FITT; four items) and the Consensus on Exercise Reporting Template (CERT; 19 items). Exercise interventions were organized into four major exercise components: aerobic training, resistance training, concurrent training, and "others."

RESULTS

The FITT assessment revealed that 53% of the trials did not report the training intensity, whereas 25% did not indicate the duration of the major exercise component within the training session. The mean CERT score was 5 out of a possible score of 19. No studies reached CERT score >10, while 13 out of the total 19 CERT items were not adequately reported by ≥75% of the studies.

CONCLUSION

This study highlights that the exercise interventions following bariatric surgery are poorly reported, non-transparent, and generally not replicable. This precludes understanding the dose-response association of exercise and health-related effects and requires action to improve this scientific field.

Skeletal effects of sleeve gastrectomy, by sex and menopausal status and in comparison to Roux-en-Y gastric bypass surgery

Context

Roux-en-Y gastric bypass (RYGB) has deleterious effects on bone mass, microarchitecture, and strength. Data are lacking on the skeletal effects of sleeve gastrectomy (SG), now the most commonly performed bariatric surgical procedure.

Objective

We examined changes in bone turnover, areal and volumetric bone mineral density (aBMD, vBMD), and appendicular bone microarchitecture and estimated strength after SG. We compared the results to those previously reported after RYGB, hypothesizing lesser effects after SG than RYGB.

Design Setting Participants

Prospective observational cohort study of 54 adults with obesity undergoing SG at an academic center.

Main Outcome Measures

Skeletal characterization with biochemical markers of bone turnover, dual-energy X-ray absorptiometry (DXA), quantitative computed tomography (QCT), and high-resolution peripheral QCT (HR-pQCT) was performed preoperatively and 6- and 12-months postoperatively.

Results

Over 12 months, mean percentage weight loss was 28.8%. Bone turnover marker levels increased, and total hip aBMD decreased -8.0% (95% CI -9.1%, -6.7%, p<0.01). Spinal aBMD and vBMD declines were larger in postmenopausal women than men. Tibial and radial trabecular and cortical microstructure worsened, as did tibial estimated strength, particularly in postmenopausal women. When compared to data from a RYGB cohort with identical design and measurements, some SG biochemical, vBMD, and radial microstructural parameters were smaller, while other changes were not.

Conclusions

Bone mass, microstructure, and strength decrease after SG. Some skeletal parameters change less after SG than after RYGB, while for others, we find no evidence for smaller effects after SG. Postmenopausal women may be at highest risk of skeletal consequences after SG.

Nutritional Behavior of Patients with Bone Diseases: A Cross-Sectional Study from Austria

BACKGROUND

A balanced diet rich in calcium and protein is recommended for bone-healthy people and osteoporosis patients, but it may also be important for rare bone disease (RBD). Little data is available on RBD and diet. Therefore, the aim of this study was to evaluate the nutritional behavior of patients with RBD.

METHODS

This single-center, cross-sectional, questionnaire-based study assessed the nutritional behavior of RBD patients (X-linked hypophosphatemia (XLH), osteogenesis imperfecta (OI), hypophosphatasia (HPP)), osteoporosis (OPO) patients and healthy controls (CTRL). The nutritional questionnaire comprised 25 questions from seven nutritional areas. The associations between socioeconomic factors and BMI were assessed by age-adjusted univariate analysis of covariance (ANCOVA).

RESULTS

Fifty patients with RBD (17 OI, 17 HPP, 16 XLH; mean age of 48.8 ± 15.9, 26.0% male, mean BMI 26.2 ± 5.6), 51 with OPO (mean age 66.6 ± 10.0, 9.8% male, mean BMI 24.2 ± 3.9) and 52 CTRL (mean age 50.8 ± 16.3, 26.9% male, mean BMI 26.4 ± 4.7) participated. Twenty-six (52.0%) RBD, 17 (33.4%) OPO and 24 (46.1%) CTRL were overweight or obese according to BMI. Only a minority of RBD, OPO and CTRL had a daily intake of at least three portions of milk or milk products (17.3% RBD, 15.6% OPO, 11.6% CTRL, p = 0.453). In general, similar nutritional behavior was observed between the three subgroups. However, significant differences were found in caffeine consumption (p = 0.016), fruit/vegetable juice consumption (p = 0.034), portions of fish per week (p = 0.044), high-fat meals per week (p = 0.015) and consumption of salty snacks (p = 0.001).

CONCLUSION

Nutritional counseling, controlling BMI and ensuring sufficient calcium and protein intake are crucial in patients with osteoporosis as well as in rare bone diseases. Vitamin D does not appear to be sufficiently supplied by the diet, and therefore supplementation should be considered in patients with bone diseases.

Protein Supplements with Short Peptides Are Better than Complex Protein-Based Supplements on Improving Early Fat-Free Mass Loss Following Bariatric Surgery: A Retrospective Cohort Study

INTRODUCTION

Bariatric surgery (BS) patients are advised to consume protein supplements to prevent fat-free mass (FFM) loss. However, limited research has explored the efficacy of diverse protein presentations on FFM preservation. This study assesses if short peptide-based (SPB) supplements surpass complex protein-based (CPB) supplements in reducing early FFM loss post-surgery.

METHODS

In this retrospective cohort study, 138 patients who underwent BS other than Roux-en-Y-gastric bypass (RYGB) between January 2021 and March 2021 at the Department of Bariatric Surgery of the Third People's Hospital of Chengdu were included for analysis. Patients were divided into two groups based on their consumption of protein supplements after surgery: SPB group and CPB group. Multiple linear regressions separated by sex were employed to examine the associations between SPB supplements and FFM loss and percentage of FFM (%FFM) loss, respectively.

RESULTS

Among participants, 69.6% were female, with a mean age of 33.3 years. In multiple linear regression analyses, SPB supplements were significantly and positively associated with a lower FFM loss in both female (ꞵ =  - 1.14, P = 0.047) and male (ꞵ =  - 2.36, P = 0.024), and were positively associated with a lower %FFM loss in both female (ꞵ =  - 1.83) and male (ꞵ =  - 2.26) but only significant in male (P = 0.049).

CONCLUSION

SPB supplements may be more effective in preventing early FFM loss after BS, compared to CPB supplements, particularly among male patients. Therefore, SPB supplements may be recommended to patients undergoing BS. Further research is needed to validate these findings.

Effects of a supervised exercise training on body composition after bariatric surgery: a randomized controlled trial

OBJECTIVE

This study aimed to determine the effects of a multicomponent exercise intervention during the first year post-bariatric surgery (BS) on body composition, weight loss (WL), energy expenditure, and nutrient intake.

METHODS

A total of 84 patients were included in this study and were randomly assigned to either an exercise group (n = 41) or a control group (n = 20). The exercise group participated in a multicomponent exercise program that began 1-month post-BS, whereas the control group received only standard medical care post-BS. Body composition was assessed by dual-energy x-ray absorptiometry, and physical activity energy expenditure was assessed by accelerometers. Nutritional intake was assessed through a 4-day food diary.

RESULTS

A total of 6-months post-BS, exercise was found to be effective in mitigating the loss of lower-limb and appendicular lean mass (LM), as well as favoring trunk fat mass (FM) loss. Moreover, it further decreased percent FM and promoted additional excess WL. After 12 months, exercise not only reduced waist circumference but also helped to lessen the loss of total, trunk, and appendicular LM.

CONCLUSIONS

Exercise further induced trunk fat mass, percent FM, excess WL, and waist circumference reductions. Moreover, exercise attenuated the loss of total and regional LM.

Effect of Nutritional Deprivation after Sleeve Gastrectomy on Bone Mass, Periostin, Sclerostin and Semaphorin 4D: A Two-Year Longitudinal Study

Bariatric surgery induces bone loss, but the exact mechanisms by which this process occurs are not fully known. The aims of this 2-year longitudinal study were to (i) investigate the changes in areal bone mineral density (aBMD) and bone turnover markers following sleeve gastrectomy (SG) and (ii) determine the parameters associated with the aBMD variations. Bone turnover markers, sclerostin, periostin and semaphorin 4D were assessed before and 1, 12 and 24 months after SG, and aBMD was determined by DXA at baseline and after 12 and 24 months in 83 patients with obesity. Bone turnover increased from 1 month, peaked at 12 months and remained elevated at 24 months. Periostin and sclerostin presented only modest increases at 1 month, whereas semaphorin 4D showed increases only at 12 and 24 months. A significant aBMD decrease was observed only at total hip regions at 12 and 24 months. This demineralisation was mainly related to body weight loss. In summary, reduced aBMD was observed after SG in the hip region (mechanical-loading bone sites) due to an increase in bone turnover in favour of bone resorption. Periostin, sclerostin and semaphorin 4D levels varied after SG, showing different time lags, but contrary to weight loss, these biological parameters did not seem to be directly implicated in the skeletal deterioration.

Long-term trajectories of bone metabolism parameters and bone mineral density (BMD) in obese patients treated with metabolic surgery: a real-world, retrospective study

PURPOSE

Potential negative effects of metabolic surgery on skeletal integrity remain a concern, since long-term data of different surgical approaches are poor. This study aimed to describe changes in bone metabolism in subjects with obesity undergoing both Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

METHODS

A single center, retrospective, observational clinical study on real-world data was performed enrolling subjects undergoing metabolic surgery.

RESULTS

123 subjects were enrolled (males 31: females 92; ages 48.2 ± 7.9 years). All patients were evaluated until 16.9 ± 8.1 months after surgery, while a small group was evaluated up to 4.5 years. All patients were treated after surgery with calcium and vitamin D integration. Both calcium and phosphate serum levels significantly increased after metabolic surgery and remained stable during follow-up. These trends did not differ between RYGB and SG (p = 0.245). Ca/P ratio decreased after surgery compared to baseline (p < 0.001) and this decrease remained among follow-up visits. While 24-h urinary calcium remained stable across all visits, 24-h urinary phosphate showed lower levels after surgery (p = 0.014), also according to surgery technique. Parathyroid hormone decreased (p < 0.001) and both vitamin D (p < 0.001) and C-terminal telopeptide of type I collagen (p = 0.001) increased after surgery.

CONCLUSION

We demonstrated that calcium and phosphorous metabolism shows slight modification even after several years since metabolic surgery, irrespective of calcium and vitamin D supplementation. This different set point is characterized by a phosphate serum levels increase, together with a persistent bone loss, suggesting that supplementation alone may not ensure the maintenance of bone health in these patients.

Role of the exercise professional in metabolic and bariatric surgery

Background

Physical activity (PA) is important for the long-term health and weight management of patients who undergo metabolic and bariatric surgery (MBS). However, the roles of exercise professionals in MBS settings have not been systematically determined.

Objectives

To investigate: (1) who are the professionals implementing PA programming in MBS clinical settings; and (2) what patient-centric tasks do they perform?

Setting

Clinical and academic exercise settings worldwide.

Methods

This multimethod study included a scoping review of PA programs in MBS described in the research literature. Data about job tasks were extracted and provided to 10 experts to sort into categories. Cluster analysis was utilized to find the hierarchical structure of tasks. A Delphi process was used to agree on a final model.

Results

The majority of PA professionals were exercise physiologists in the USA and physiotherapists or other types of exercise professionals elsewhere. Forty-three tasks were identified, the most reported being: supervision of exercise, fitness testing, and exercise prescription. Seven higher-order categories were determined: (1) Exercise-related health assessment, (2) Body composition and physical fitness assessment, (3) Lifestyle physical activity and sedentary behavior assessment, (4) Education, instruction, and prescription, (5) Exercise monitoring, (6) Behavioral counseling and psychosocial support, and (7) Dietary support. The following statements were rated an average of 9.0, classifying them as "imperative": 1) "Pre- and post-operative PA/exercise guidelines for MBS patients are needed", 2) "MBS programs need to include PA/exercise as part of multidisciplinary care".

Conclusions

The expert group reached a consensus on 7 major classifications of job tasks for the exercise professional. It is important for governing medical associations across the world to formally recognize experienced exercise professionals as playing pivotal roles in continuing, multidisciplinary care for MBS patients. These findings also provide evidence-based information in the effort to solidify these positions within the greater context of healthcare.

Changes in Fat-Free Mass, Protein Intake and Habitual Physical Activity Following Roux-en-Y Gastric Bypass Surgery: A Prospective Study

PURPOSE

Large inter-individual variations in post-bariatric fat-free mass loss (FFML) are observed, which might relate to differences in protein intake and physical activity across patients. We performed repetitive assessments of protein intake and physical activity before and after banded Roux-en-Y gastric bypass surgery, and examined its relations to FFML during 6 months of follow-up.

MATERIALS AND METHODS

FFML (bio-impedance analyses), protein intake (24-h dietary recalls) and moderate-to-vigorous physical activity (MVPA; activPAL) were assessed in 28 patients (4 males, age 42 ± 12 years) before surgery and at 1-, 3- and 6-months post-surgery. Changes in protein intake and MVPA were evaluated with mixed model analysis, whereas associations with FFML were assessed by univariate regression analysis.

RESULTS

Six-month FFML was -7.3 ± 3.6 kg. Protein intake decreased from 80 ± 29 g/day (pre-surgery) to 45 ± 26 g/day (1 month post-surgery (P < 0.001)) and did not improve thereafter (51 ± 21 g/day; P > 0.05). Seven participants (25%) consumed ≥ 60 g protein/day at 6 months post-surgery. Participants performed 7394 ± 2420 steps/day in 54 ± 20 min/day of MVPA, which did not change from pre- to post-surgery (P > 0.05). A higher step count (B = -0.002; 95%CI = [-0.004 - 0.000]; P = 0.048) and higher level of MVPA (B = -0.29; 95%CI = [-0.54 - -0.03]; P = 0.018) were related to a lower FFML.

CONCLUSION

A lower post-surgery FFML was attributable to higher MVPA levels but not protein intake. This may be due to the low total protein intake and the observation that only a minority of patients achieved a protein intake ≥ 60 g/day. Future studies should focus on interventions to increase post-bariatric protein intake and MVPA levels.

Skeletal Effects of Sleeve Gastrectomy in Adolescents and Young Adults: A 2-Year Longitudinal Study

CONTEXT

Vertical sleeve gastrectomy (VSG) is an increasingly common tool to achieve weight loss and improve metabolic health in adolescents and young adults with obesity, although it may adversely affect bone health.

OBJECTIVE

This work aimed to evaluate the effect of VSG on bone health in youth.

METHODS

An observational 2-year study was conducted at a tertiary care center of 66 patients aged 13 to 24 years with moderate-to-severe obesity meeting criteria for VSG. The patients underwent VSG (n = 30) or nonsurgical (n = 36) management per the decision of patient and clinical team. Main outcome measures included dual-energy x-ray absorptiometry (DXA) and high-resolution peripheral quantitative computed tomography (HRpQCT) measures of bone mineral density (BMD), geometry, and microarchitecture.

RESULTS

VSG patients achieved 25.3 ± 2.0% weight loss at 2 years (P < .001) while control subjects gained 4.0 ± 2.0% (P = .026). Total hip BMD declined 8.5 ± 1.0% following VSG compared with 0.1 ± 1.0% gain in controls (P < .001), with similar results at the femoral neck (P < .001). Total volumetric BMD (vBMD) decreased both at the distal radius and tibia following VSG (P < .001) driven primarily by trabecular vBMD loss (P < .001). Two-year changes in cortical vBMD did not differ between groups, though cortical porosity decreased following VSG both at the radius and tibia (P = .048 and P < .001). Cortical thickness increased in controls but not in VSG (P = .022 and P = .002 for between-group comparisons at the radius and tibia, respectively). Following VSG, estimated failure load decreased at the radius and did not demonstrate the physiologic increases at the tibia observed in controls.

CONCLUSION

VSG leads to progressive changes in bone health over 2 years, and may lead to increased skeletal fragility in adolescents and young adults.

Clinical Outcomes of Bariatric Surgery Before Spinal Fusion: A Systematic Review

INTRODUCTION

Morbidly obese patients are at increased risk for intraoperative and postoperative complications following spinal fusion. Preoperative weight loss can improve clinical outcomes. The present systematic literature review is aimed to evaluate the hypothesis that bariatric surgery before spinal fusion surgery is associated with higher rates of complications and revisions.

METHODS

Three databases were queried for literature pertaining to bariatric surgery prior to spinal fusion. A 2-author screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Methodologic index for non-randomized studies criteria was used to objectively assess the methodologic quality of the studies reviewed. Retrospective cohort studies in which the patients underwent bariatric surgery were included.

RESULTS

Four retrospective cohort studies consisting of a total of 180,090 patients were included. Length of stay was significantly shorter for the bariatric surgery (BS) group patients than the control (C) groups patients (P = 0.009). There were no significant differences in 1-year mortality rate (P = 1.0), readmission rate (P = 0.86), overall postoperative complications (P = 0.83), and postoperative infections (P = 0.97) between the BS and C groups.

CONCLUSIONS

There were no consistent differences in rates of postoperative complications, infections, hospital readmission, and mortality between obese patients with bariatric surgery prior to spinal fusion and control group patients. The present study does not support the hypothesis that bariatric surgery before spinal fusion contributes to a higher rate of postoperative complications in patients undergoing spinal fusion.

Nutritional Interventions for Patients with Severe Obesity Seeking Bariatric Surgery

Bariatric surgery (BS) is usually considered when other weight-loss treatments have failed, and remains an effective long-term treatment for severe obesity and its related medical complications [...].

French recommendations on the prevention and treatment of osteoporosis secondary to bariatric surgery

INTRODUCTION

This article presents the initial recommendations of the Groupe de Recherche et d'Information sur les Ostéoporoses (Osteoporosis Research and Information Group [GRIO]) and the Société Française de Rhumatologie (French Rheumatology Society [SFR]) on the prevention and treatment of osteoporosis secondary to bariatric surgery.

METHODS

The recommendations were produced by a working group comprising 4 expert rheumatologists, 3 medically qualified nutritionists, 2 obesity surgeons, 1 physical activity specialist, and 1 patient-association representative.

RESULTS

The following generally recommended measures apply to all patients with an indication for bariatric surgery or who have already undergone bariatric surgery: normalize calcium and protein intake, attain a 25(OH) vitamin D concentration of between 30 and 60ng/mL; prevent the risk of falls, and introduce a suitable regimen of physical activity. An initial assessment of fracture risk should be routinely performed - ideally before the first bariatric surgery procedure - (i) in the case of RYGB and biliopancreatic diversion, regardless of age, (ii) in patients at high risk of fracture, regardless of age, and (iii) in all menopausal women and all men ≥ 50 years old, regardless of the type of bariatric surgical procedure. The fracture risk assessment is based on a determination of osteoporosis risk factors and bone mineral density measurements. Anti-osteoporosis treatment - zoledronic acid as the first line of treatment - is indicated for menopausal women and men ≥ 50 years old with (i) a history of severe fracture, regardless of T-score, (ii) a history of non-severe fracture and a T-score ≤ -1, and (iii) no history of fracture and a T-score ≤ -2.

CONCLUSIONS

There is an increased risk of fracture after bariatric surgery. Clinicians should focus their attention on patients at high fracture risk such as postmenopausal women and men older than 50 years. More research is necessary to direct and support guidelines.

Zoledronic Acid for prevention of bone and muscle loss after BAriatric Surgery (ZABAS)-a study protocol for a randomized controlled trial

Background

Bariatric surgery has adverse effects on the muscular-skeletal system with loss of bone mass and muscle mass and an increase in the risk of fracture. Zoledronic acid is widely used in osteoporosis and prevents bone loss and fracture. Bisphosphonates may also have positive effects on skeletal muscle. The aim of this study is to investigate the effects of zoledronic acid for the prevention of bone and muscle loss after bariatric surgery. 

Methods/design

This is a randomized double-blind placebo-controlled study. Sixty women and men with obesity aged 35 years or older will complete baseline assessments before randomization to either zoledronic acid (5 mg in 100 ml isotonic saline) or placebo (100 ml isotonic saline only) 3 weeks before surgery with Roux-en-Y-gastric bypass (RYGB) or sleeve gastrectomy (SG). Follow-up assessments are performed 12 and 24 months after surgery. The primary outcome is changes in lumbar spine volumetric bone mineral density (vBMD) assessed by quantitative computed tomography (QCT). Secondary bone outcomes are changes in proximal femur vBMD assessed by QCT. Changes in cortical and trabecular bone microarchitecture and estimated bone strength will be assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT). Cortical material bone strength at the mid-tibia diaphysis will be assessed using microindentation and fasting blood samples will be obtained to assess biochemical markers of bone turnover and calcium metabolism. 

Secondary muscle outcomes include whole body lean mass assessed using dual-energy X-ray absorptiometry. Dynamometers will be used to assess handgrip, shoulder, ankle, and knee muscle strength. Short Physical Performance Battery, 7.6-m walking tests, 2-min walking test, and a stair climb test will be assessed as biomarkers of physical function. Self-reported physical activity level is assessed using International Physical Activity Questionnaire (IPAQ).

Discussion

Results from this study will be instrumental for the evidence-based care of patients undergoing bariatric surgery.

Trial registration

ClinicalTrials.gov NCT04742010. Registered on 5 February 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06766-z.

BONE HEALTH ASSESSMENT OF ELDERLY PATIENTS UNDERGOING BARIATRIC SURGERY

BACKGROUND

Bariatric surgery promotes changes in body composition, that can include the loss of bone mineral density (BMD). There is a lack of studies on the evolution of bone health of elderly people who underwent bariatric surgery, in general, and when comparing the gastric bypass (GB) and sleeve gastrectomy (SG) techniques.

OBJECTIVE

To evaluate the bone health of elderly patients with obesity undergoing bariatric surgery.

METHODS

This is a prospective randomized clinical study, that was carried out with individuals of both sexes, ≥65 years, undergoing GB or SG and who met the inclusion criteria. Age, gender and comorbidities (type 2 diabetes mellitus, arterial hypertension, dyslipidemia and osteoarthrosis) were collected and analyzed at baseline. Anthropometric data (weight, body mass index, percentage of weight loss, percentage of excess weight loss), laboratory tests related to bone health and bone mineral density were analyzed before and 24 months after surgery.

RESULTS

A total of 36 patients (GB, n=18; SG, n=18) were evaluated. At baseline, except for sex and preoperative body mass index, which was higher in GB, groups were similar. After 24 months, GB was superior for weight loss (%WL) and excess weight loss (%EWL). Regarding bone health, a significant decrease of BMD was observed in the spine, total proximal femur and femoral neck in all groups, with an average decrease of 5.1%, 10.5% and 15.1%, respectively. In addition, the observed decrease in BMD was up to 25% in the total femur after 24 months, six patients went from normal BMD to osteopenia and one from osteopenia to osteoporosis. There was no difference in parathormone values. However, there was an association between the increase in parathormone and the decrease in BMD in the spine, mainly in the GB group. There was no association between %WL and %EWL with the reduction in BMD.

CONCLUSION

Bariatric surgery was related to the reduction of BMD in elderly patients, but there was no statistical difference between the two surgical techniques.

Exercise and bariatric surgery: A systematic review and meta-analysis of the feasibility and acceptability of exercise and controlled trial methods

This systematic review and meta-analysis assessed the feasibility and acceptability of exercise and controlled trial methods in adults awaiting or having undergone bariatric surgery (BS). Search methods used to identify relevant articles were inclusion of articles identified in a systematic review, new database search of articles published 2019-2021, and hand searching reference lists. Titles/abstracts and full-texts were screened by two reviewers independently against inclusion criteria: adults awaiting or having undergone BS, controlled trial, exercise group compared with a comparison group without exercise. Twenty-eight articles were reviewed; most interventions were supervised, performed after BS, and lasted ≤13 weeks. Pooled data for exercise intervention attendance and dropout rates were 84% (k = 10) and 5% (k = 19), respectively, though possibly misestimated due to poor/selective reporting. Median study and recruitment duration were 18 weeks and 24 months, respectively, with a pooled enrollment rate of 2.5 participants/month. Pooled data for refusal to participate, enrollment, and retention rates were 23% (k = 16), 43% (k = 18), and 87% (k = 26), respectively. Despite the lack of data available in studies included, exercise and controlled trial methods seem feasible and acceptable for adults awaiting or having undergone BS. To better identify methodological or practical challenges, and assess bias, better reporting of feasibility and acceptability indicators is needed in future studies.

Skelettale Auswirkungen bariatrischer Chirurgie

Bei zunehmender Prävalenz der Adipositas sind in Deutschland ca. 54% der Bevölkerung übergewichtig oder adipös, wobei mit steigendem Übergewicht das Risiko für weitere Erkrankungen, wie z. B. Diabetes mellitus Typ 2, Herzinsuffizienz, arterielle Hypertonie u. a. stark ansteigt. Die Reduktion des Körpergewichtes ist daher aus verschiedenen Gesichtspunkten anzustreben. Viele Patientinnen und Patienten mit Adipositas haben bereits vor einer möglichen Operation einen Mangel an Vitamin D und Calcium und zeigen in Laboruntersuchungen entsprechende Defizite. Die konservative Behandlung der Adipositas aus Ernährungs-, Bewegung- und Verhaltenstherapie bildet die Basis der möglichen Therapiemaßnahmen. Bei Versagen der konservativen Behandlungsoptionen ergibt sich ab einem Body-Mass-Index (BMI) von über 40 kg/m2 die Indikation zur operativen Therapie, ab einem BMI von 50 kg/m2 besteht unter bestimmten Voraussetzungen die primäre Indikation zur Durchführung einer bariatrisch-chirurgischen Maßnahme. Zu den in Deutschland am häufigsten empfohlenen operativen Verfahren, die in der Regel laparoskopisch durchgeführt werden, gehören weiterhin die Implantation eines Magenbands, die Bildung eines Magenschlauchs (Gastric-sleeve-Resektion), die Anlage eines proximalen Roux-en-Y-Magenbypass oder eines Omega-loop-Magenbypass. Neben der angestrebten Reduktion des Übergewichtes durch ihre restriktiven wie malabsorptiven Wirkungen führen diese OP-Methoden in unterschiedlichem Ausmaß zu Veränderungen des Kalzium-Stoffwechsels u. a. mit Hypocalcämie, Vitamin-D-Defizit und Erhöhung des Serum-Parathormons, was in einem erhöhten Frakturrisiko, Veränderungen der Knochendichte und der Mikroarchitektur des Knochens münden kann. In der Nachsorge nach bariatrischen Operationen sind daher eine ausreichende Supplementierung verschiedener Vitamine, Mineralien und Spurenelemente, die regelmäßige Kontrolle der Laborparameter und der Knochendichte sowie ein angepasstes körperliches Training wichtig. Aus osteologischer Sicht kommt bei diagnostizierter Osteoporose insbesondere eine intravenöse antiresorptive Therapie in Betracht.

Changes in the Bone Mineral Density after Sleeve Gastrectomy vs. Roux-En-Y Gastric Bypass 2 Years after Surgery

The aim of this study was to compare the analytical and densitometric changes 2 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). A retrospective study of a prospectively collected database was performed. Morbidly obese patients undergoing RYGB or SG, as primary bariatric procedures, were included. Weight loss; analytical levels of parathormone (PTH), vitamin D, and calcium; and densitometric parameters were investigated. In total, 650 patients were included in the study, and 523 patients (80.5%) underwent RYGB and 127 (19.5%) SG. There were no significant differences in excess weight loss at 24 months between both groups. When comparing preoperative and postoperative values, a significantly greater increase in PTH values was observed in the RYGB group, whereas there were no significant differences in calcium and vitamin D levels. The mean t-score values decreased after surgery at all the locations and in both groups. The reduction in the t-score was significantly greater in the RYGB group at the femoral trochanter and lumbar spine. A decrease in bone mineral density (BMD) was observed after both techniques. The mean BMD decrease was significantly greater in the femoral trochanter and lumbar spine after RYGB.

Analysis and Research on the Impact of Physical Exercise on Residents’ Health Based on the Improved BP Neural Network Model

With the rapid improvement of social economy and the enhancement of people's health awareness, it is necessary to make an in-depth analysis of the rationality of physical exercise and the physical quality of residents. Hence, this study aims to explore the algorithm optimization of the improved BP model to analyze the effect of exercise intervention on improving public sports effect. K-clustering and Levenberg–Marquardt algorithm were used to construct an improved BP neural network model to determine the sample clustering center, as well as the weight and threshold of the indicators, so as to optimize the analysis algorithm of improving public sports effect. MATLAB simulation shows that under the target error conditions of 0.01, 0.005, 0.001, and 0.0001, the target error rate and iteration times of the improved BP model are better than the standard BP model, and the time consumption is shorter, which can be conducive to more accurately analyzing the changes of improving public sports effect under exercise intervention. Therefore, the improved BP model can effectively solve the problems of data clustering and result error rate adjustment in the process of improving public sports effect analysis and improve the analysis speed and accuracy.

The Effect of Vitamin D Supplementation on Serum 25-Hydroxy Vitamin D in the Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-Analysis of Randomized Clinical Trials

Currently, there is no consensus on the optimal vitamin D administration in bariatric patients. The present systematic review and meta-analysis were conducted to examine the effect of vitamin D supplements on serum level of 25(OH) vitamin D in the patients undergoing bariatric surgery (BS).Random model effects were used to estimate standardized mean difference (SMD) with a 95% confidence interval (CI). Nine clinical trials were included in the meta-analysis. Vitamin D supplementation in patients undergoing BS modestly improves vitamin D status (SMD, 0.53; 95% CI, 0.28, 0.77) particularly, in the dosages above 2850 IU/day and in the patients with BMI greater than 50 kg/m². Vitamin D supplementation was associated with prevention of raising of the PTH serum concentration and without impact on serum calcium levels.

Nutritional Status in Chinese Patients with Obesity Following Sleeve Gastrectomy/Roux-en-Y Gastric Bypass: A Retrospective Multicenter Cohort Study

Metabolic surgery (MS) is one of the most effective therapies for treating obesity. Due to the lack of multicenter cohort research on nutritional evaluations after surgery in Chinese patients, we explored the changes in nutritional status following MS in Chinese patients. This was a retrospective study of patients (n = 903) who underwent sleeve gastrectomy (SG) (n = 640) or Roux-en-Y gastric bypass (RYGB) (n = 263) for obesity at five different hospitals in China between 17 February 2011, and 20 December 2019. Major nutrients were evaluated at baseline and 1, 3, 6, and 12 months postoperatively. Hb levels decreased, and anemia prevalence increased at 12 months after MS in the premenopausal female group. Moreover, patients with preoperative anemia had an increased risk of postoperative anemia. The ferritin levels (p < 0.001) decreased and iron deficiency increased (p < 0.001) at 12 months after MS among premenopausal females. No significant changes in folate deficiency and vitamin B12 deficiency were found throughout the study. The bone mineral density (BMD) of the femoral neck, lumbar spine, and total hip significantly decreased from baseline to 12 months after MS; however, no new patients developed osteopenia or osteoporosis after MS. Based on 12 months of follow-up, premenopausal females presented a high incidence of anemia after MS. Although we found no differences in osteopenia and osteoporosis prevalence after MS, the BMD did decrease significantly, which suggests that nutrient supplements and long-term follow-up are especially necessary postoperation.

Bariatric Surgery and Osteoporosis

It has been increasingly acknowledged that bariatric surgery adversely affects skeletal health. After bariatric surgery, the extent of high-turnover bone loss is much greater than what would be expected in the absence of a severe skeletal insult. Patients also experience a significant deterioration in bone microarchitecture and strength. There is now a growing body of evidence that suggests an association between bariatric surgery and higher fracture risk. Although the mechanisms underlying the high-turnover bone loss and increase in fracture risk after bariatric surgery are not fully understood, many factors seem to be involved. The usual suspects are nutritional factors and mechanical unloading, and the roles of gut hormones, adipokines, and bone marrow adiposity should be investigated further. Roux-en-Y gastric bypass (RYGB) was once the most commonly performed bariatric procedure worldwide, but sleeve gastrectomy (SG) has now become the predominant bariatric procedure. Accumulating evidence suggests that RYGB is associated with a greater reduction in BMD, a greater increase in markers of bone turnover, and a higher risk of fracture than SG. These findings should be taken into consideration in determining the most appropriate bariatric procedure for patients, especially those at higher fracture risk. Before and after all bariatric procedures, sufficient calcium, vitamin D and protein intake, and adequate physical activity, are needed to counteract negative impacts on bone. There are no studies to date that have evaluated the effect of osteoporosis treatment on high-turnover bone loss after bariatric surgery. However, in patients with a diagnosis of osteoporosis, anti-resorptive agents may be considered.

The Impact of Bariatric Surgery on Bone Health: State of the Art and New Recognized Links

Bariatric surgery (BS) is the most effective therapy for severe obesity, which improves several comorbidities (such as diabetes, hypertension, dyslipidemia, among others) and results in marked weight loss. Despite these consensual beneficial effects, sleeve gastrectomy and Roux-en-Y gastric bypass (the two main bariatric techniques) have also been associated with changes in bone metabolism and progressive bone loss. The objective of this literature review is to examine the impact of bariatric surgery on bone and its main metabolic links, and to analyze the latest findings regarding the risk of fracture among patients submitted to bariatric surgery.

Short-Term Changes on Body Composition After Sleeve Gastrectomy and One Anastomosis Gastric Bypass

Introduction: Changes in body composition after different bariatric surgeries have been studied extensively, but most of them have emphasized on Roux-en-Y gastric bypass. Only a few studies have assessed the effects of sleeve gastrectomy (SG). Also, the effect of one anastomosis gastric bypass (OAGB) on body composition is not fully apprehended. Furthermore, there is no agreement on how much fat-free mass (FFM) loss is tolerable in weight loss interventions. Therefore, we decided to assess the reduction in fat mass (FM) and FFM at 1, 3, 6, and 12 months after two types of bariatric surgery in a single center. Methods: In the current retrospective cross-sectional study, the patients' hospital records were analyzed. We included patients who had SG or OAGB and a complete 1-year follow-up record. We recorded demographic data as well as weight, body mass index (BMI), FM, and FFM before and at 1, 3, 6, and 12 months after surgery in a predesigned checklist. Results: We analyzed 311 patients (43 males and 268 females) in the SG (N = 192, 61.7%) and OAGB (N = 119, 38.3%) groups. Both the SG and OAGB groups demonstrated a statistically significant reduction in weight, BMI, FM, and FFM indices at 12 months after the intervention (P < .001). Moreover, no statistically significant difference was observed between the SG and OAGB groups regarding the mean of all body composition indices at 3, 6, and 12 months after the intervention. Conclusion: We found that SG and OAGB effectively decreased weight and body composition indices, comprising FM and FFM, with no significant difference between each other.

Can exercise promote additional benefits on body composition in patients with obesity after bariatric surgery? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Bariatric surgery is the most effective treatment for patients with severe obesity, but success rates vary substantially. Exercise is recommended after bariatric surgery to reduce weight regain but the effectiveness remains undetermined on weight loss due to conflicting results. It is also unclear what should be the optimal exercise prescription for these patients. A systematic review and meta-analysis of randomized controlled trials on the effects of exercise on body weight (BW), anthropometric measures, and body composition after bariatric surgery was performed.

METHODS

PubMed/MEDLINE®, EBSCO®, Web of Science® and Scopus® databases were searched to identify studies evaluating exercise effectiveness.

RESULTS

The analysis comprised 10 studies (n = 487 participants). Exercise favored BW (-2.51kg; p = 0.02), waist circumference (-4.14cm; p = 0.04) and body mass index (-0.84kg·m-2; p = 0.02) reduction but no improvements in body composition. Combined exercise interventions were the most effective in reducing BW (-5.50kg; p < 0.01) and body mass index (-1.86kg·m-2; p < 0.01). Interventions starting >6-months after bariatric surgery were more successful in reducing BW (-5.02kg; p < 0.01) and body mass index (-1.62kg·m-2; p < 0.01).

CONCLUSION

Exercise, combined exercise regimens and interventions starting >6-months after bariatric surgery were effective in promoting BW, waist circumference and body mass index reduction. Exercise following bariatric surgery does not seem to favor body composition improvements.

The effect of protein supplements on weight loss, body composition, protein status, and micronutrients post laparoscopic sleeve gastrectomy (LSG): A Randomised Controlled Trial (RCT)

Background

Low protein intake post-bariatric surgery can result in protein malnutrition, and muscle mass loss. Authors aim to assess the effect of protein supplements on weight loss, body composition, and micronutrient status following LSG.

Methods

This is a double-blinded RCT conducted between February/2017 to January/2018. Eligible post LSG patients were randomized into the intervention group who received daily protein supplements containing 20 g of protein and placebo group received zero protein supplements. Both groups received a standardized diet. Weight loss, body composition, and micronutrient status were analyzed at 1, 3, and 6 months.

Results

48 participants were included in the final analysis (intervention: 21 and placebo:27). Excess weight loss percentage (EWL%) at 6 months was comparable between both groups (69.44 ± 21.99% and 71.40 ± 19.27% respectively). No significant difference observed in the anthropometric parameters. There was an increase in muscle mass and a decrease in muscle mass loss in the intervention group throughout the study period. However, these changes were not statistically significant. There was a significant increase in total protein (P=0.027) and magnesium (P=0.008) in the intervention group at 3 months. Albumin and iron levels were significantly higher at 6 months in the intervention group (P=0.036 & P=0.028 respectively). Other micronutrients did not differ at any time point between both groups.

Conclusion

Protein supplements resulted in significant improvement in total protein, albumin, magnesium, and iron levels post LSG. Although not significant, protein supplements helped in maintaining the muscle mass and preventing muscle mass loss.

Original article

This RCT is an original article and provides a level 2 evidence.

•

Low protein intake post-bariatric surgery results in protein malnutrition & muscle mass loss. Protein supplements may be of benefit.

•

Eligible post LSG patients were randomized into the intervention group who received daily 20 g protein supplements & placebo group.

•

No significant difference in weight, BMI, BMI change, EWL%, TWL%, and absolute weight loss. No statistically significant changes in the muscle mass.

•

Percentage of muscle mass loss was noticeably higher in the control group over the 3 timelines. Fat percentages were less in the intervention group.

•

Total protein and Albumin showed a significant increase in the intervention group.

The Effect of Exercise for the Prevention of Bone Mass After Bariatric Surgery: a Systematic Review and Meta-analysis

We aimed to assess if exercise applied after bariatric surgery (BS) improves bone mineral density (BMD) compared to usual care. Systematic search was conducted up to January 2021. Effect measures were determined using standardized mean difference (SMD) with 95% confidence interval (CI). Certainty evidence was assessed according to GRADE. Four clinical trials encompassing 340 patients were included. Exercise induced a positive BMD effect at total hip (SMD = 0.37 [95% CI 0.02, 0.71]; very low certainty evidence), femoral neck (SMD = 0.63 [95% CI 0.19, 1.06]; low certainty evidence), lumbar spine (SMD = 0.41 [95% CI 0.19, 0.62]; low certainty evidence), and 1/3 radius (SMD = 0.58 [95% CI 0.19, 0.97]; low certainty evidence). Exercise undertaken after BS seems to induce a positive effect on BMD.

Effects of physical activity and dietary supplement on fat free mass and bone mass density during weight loss - a systematic review and meta-analysis

Background: After a diet- or surgery induced weight loss almost 1/3 of lost weight consists of fat free mass (FFM) if carried out without additional therapy. Exercise training and a sufficient supply of protein, calcium and vitamin D is recommended to reduce the loss of FFM. Objective: To investigate the effect of exercise training, protein, calcium, and vitamin D supplementation on the preservation of FFM during non-surgical and surgical weight loss and of the combination of all interventions together in adults with obesity. Methods: A systematic review was performed with a pairwise meta-analysis and an exploratory network meta-analysis according to the PRISMA statement. Results: Thirty studies were included in the quantitative analysis. The pairwise meta-analysis showed for Exercise Training + High Protein vs. High Protein a moderate and statistically significant effect size (SMD 0.45; 95% CI 0.04 to 0.86), for Exercise Training + High Protein vs. Exercise Training a high but statistically not significant effect size (SMD 0.91; 95% CI -0.59 to 2.41) and for Exercise Training alone vs. Control a moderate but statistically not significant effect size (SMD 0.67; 95% CI -0.25 to 1.60). In the exploratory network meta-analysis three interventions showed statistically significant effect sizes compared to Control and all of them included the treatment Exercise Training. Conclusions: Results underline the importance of exercise training and a sufficient protein intake to preserve FFM during weight loss in adults with obesity. The effect of calcium and vitamin D supplementation remains controversial and further research are needed.

Effects of exercise training and dietary supplement on fat free mass and bone mass density during weight loss - a systematic review and meta-analysis

Background: After a diet- or surgery induced weight loss almost 1/3 of lost weight consists of fat free mass (FFM) if carried out without additional therapy. Exercise training and a sufficient supply of protein, calcium and vitamin D is recommended to reduce the loss of FFM. Objective: To investigate the effect of exercise training, protein, calcium, and vitamin D supplementation on the preservation of FFM during non-surgical and surgical weight loss and of the combination of all interventions together in adults with obesity. Methods: A systematic review was performed with a pairwise meta-analysis and an exploratory network meta-analysis according to the PRISMA statement. Results: Thirty studies were included in the quantitative analysis. The pairwise meta-analysis showed for Exercise Training + High Protein vs. High Protein a moderate and statistically significant effect size (SMD 0.45; 95% CI 0.04 to 0.86), for Exercise Training + High Protein vs. Exercise Training a high but statistically not significant effect size (SMD 0.91; 95% CI -0.59 to 2.41) and for Exercise Training alone vs. Control a moderate but statistically not significant effect size (SMD 0.67; 95% CI -0.25 to 1.60). In the exploratory network meta-analysis three interventions showed statistically significant effect sizes compared to Control and all of them included the treatment Exercise Training. Conclusions: Results underline the importance of exercise training and a sufficient protein intake to preserve FFM during weight loss in adults with obesity. The effect of calcium and vitamin D supplementation remains controversial and further research are needed.

Effects of physical activity and dietary supplement on fat free mass and bone mass density during weight loss - a systematic review and meta-analysis

Background: After a diet- or surgery induced weight loss almost 1/3 of lost weight consists of fat free mass (FFM) if carried out without additional therapy. Exercise training and a sufficient supply of protein, calcium and vitamin D is recommended to reduce the loss of FFM. Objective: To investigate the effect of exercise training, protein, calcium, and vitamin D supplementation on the preservation of FFM during non-surgical and surgical weight loss and of the combination of all interventions together in adults with obesity. Methods: A systematic review was performed with a pairwise meta-analysis and an exploratory network meta-analysis according to the PRISMA statement. Results: Thirty studies were included in the quantitative analysis. The pairwise meta-analysis showed for Exercise Training + High Protein vs. High Protein a moderate and statistically significant effect size (SMD 0.45; 95% CI 0.04 to 0.86), for Exercise Training + High Protein vs. Exercise Training a high but statistically not significant effect size (SMD 0.91; 95% CI -0.59 to 2.41) and for Exercise Training alone vs. Control a moderate but statistically not significant effect size (SMD 0.67; 95% CI -0.25 to 1.60). In the exploratory network meta-analysis three interventions showed statistically significant effect sizes compared to Control and all of them included the treatment Exercise Training. Conclusions: Results underline the importance of exercise training and a sufficient protein intake to preserve FFM during weight loss in adults with obesity. The effect of calcium and vitamin D supplementation remains controversial and further research are needed.

[Bariatric Surgery in 2022 - What Is Important for the General Practitioner?]

Bariatric Surgery in 2022 - What Is Important for the General Practitioner? Abstract. Bariatric surgery is the most efficient treatment for obesity and associated diseases. Basic knowledge about the indications, common procedures, follow-up and possible complications has become essential for primary care practice. This article explains the current standards of care in Switzerland with a focus on relevant information for the practice: nutritional aspects after bariatric surgery, necessary clinical and laboratory examinations, early detection of complications. Only intense interdisciplinary and interprofessional collaboration leads to a treatment success in morbid obesity.

Bone Response to Weight Loss Following Bariatric Surgery

Obesity is a global health challenge that warrants effective treatments to avoid its multiple comorbidities. Bariatric surgery, a cornerstone treatment to control bodyweight excess and relieve the health-related burdens of obesity, can promote accelerated bone loss and affect skeletal strength, particularly after malabsorptive and mixed surgical procedures, and probably after restrictive surgeries. The increase in bone resorption markers occurs early and persist for up to 12 months or longer after bariatric surgery, while bone formation markers increase but to a lesser extent, suggesting a potential uncoupling process between resorption and formation. The skeletal response to bariatric surgery, as investigated by dual-energy X-ray absorptiometry (DXA), has shown significant loss in bone mineral density (BMD) at the hip with less consistent results for the lumbar spine. Supporting DXA studies, analyses by high-resolution peripheral quantitative computed tomography (HR-pQCT) showed lower cortical density and thickness, higher cortical porosity, and lower trabecular density and number for up to 5 years after bariatric surgery. These alterations translate into an increased risk of fall injury, which contributes to increase the fracture risk in patients who have been subjected to bariatric surgery procedures. As bone deterioration continues for years following bariatric surgery, the fracture risk does not seem to be dependent on acute weight loss but, rather, is a chronic condition with an increasing impact over time. Among the post-bariatric surgery mechanisms that have been claimed to act globally on bone health, there is evidence that micro- and macro-nutrient malabsorptive factors, mechanical unloading and changes in molecules partaking in the crosstalk between adipose tissue, bone and muscle may play a determining role. Given these circumstances, it is conceivable that bone health should be adequately investigated in candidates to bariatric surgery through bone-specific work-up and dedicated postsurgical follow-up. Specific protocols of nutrients supplementation, motor activity, structured rehabilitative programs and, when needed, targeted therapeutic strategies should be deemed as an integral part of post-bariatric surgery clinical support.

Bariatric surgery and skeletal health: A narrative review and position statement for management by the European Calcified Tissue Society (ECTS)

CONTEXT

Numerous studies have demonstrated detrimental skeletal consequences following bariatric surgery.

METHODS

A working group of the European Calcified Tissue Society (ECTS) performed an updated review of existing literature on changes of bone turnover markers (BTMs), bone mineral density (BMD), and fracture risk following bariatric surgery and provided advice on management based on expert opinion.

LITERATURE REVIEW

Based on observational studies, bariatric surgery is associated with a 21-44% higher risk of all fractures. Fracture risk is time-dependent and increases approximately 3 years after bariatric surgery. The bariatric procedures that have a malabsorptive component (including Roux-en-Y Gastric bypass (RYGB) and biliopancreatic diversion (BPD)) have clearly been associated with the highest risk of fracture. The extent of high-turnover bone loss suggests a severe skeletal insult. This is associated with diminished bone strength and compromised microarchitecture. RYGB was the most performed bariatric procedure worldwide until very recently, when sleeve gastrectomy (SG) became more prominent. There is growing evidence that RYGB is associated with greater reduction in BMD, greater increase in BTMs, and higher risk of fractures compared with SG but RCTs on optimal management are still lacking.

EXPERT OPINION

In all patients, it is mandatory to treat vitamin D deficiency, to achieve adequate daily calcium and protein intake and to promote physical activity before and following bariatric surgery. In post-menopausal women and men older than 50 years, osteoporosis treatment would be reasonable in the presence of any of the following criteria: i) history of recent fragility fracture after 40 years of age, ii) BMD T-score ≤ -2 at hip or spine, iii) FRAX score with femoral neck BMD exceeding 20% for the 10-year major osteoporotic fracture probability or exceeding 3% for hip fracture. Zoledronate as first choice should be preferred due to intolerance of oral formulations and malabsorption. Zoledronate should be used with caution due to hypocemia risk. It is recommended to ensure adequate 25-OH vitamin D level and calcium supplementation before administering zoledronate.

CONCLUSIONS

The bariatric procedures that have a malabsorptive component have been associated with the highest turnover bone loss and risk of fracture. There is a knowledge gap on osteoporosis treatment in patients undergoing bariatric surgery. More research is necessary to direct and support guidelines.

Changes in bone mineral density following laparoscopic sleeve gastrectomy: 2-year outcomes

BACKGROUND

Emerging evidence suggests that sleeve gastrectomy (SG) leads to significant bone mineral density (BMD) losses, but there is a paucity of studies evaluating skeletal consequences beyond 12-months post-operatively.

OBJECTIVES

To evaluate BMD changes 2 years postoperatively.

SETTING

A university hospital.

METHODS

Thirty-three women (mean age: 34.4 ± 12.3 years) who underwent SG and completed 24 months of follow-up were evaluated prospectively at baseline and at 3 (M3), 6 (M6), 12 (M12), and 24 (M24) months postoperatively. Data collected included BMD at the total hip, femoral neck, and lumbar spine measured by dual-energy x-ray absorptiometry and anthropometrics, biochemical, nutritional, and physical activity parameters.

RESULTS

At M24, patients achieved a mean body mass index and excess weight loss of 32.4 ± 5.1 kg/m² and 64.5 ± 21.4%, respectively; however, weight stabilized at M12. Femoral neck BMD decreased significantly from baseline to M24 (.924 ± .124 versus .870 ± .129 g/cm², P < .001), with no change between M12 and M24 (P = .273). Total hip BMD decreased significantly from baseline to M24 (1.004 ± .105 versus .965 ± .132 g/cm², P < .001) but increased between M12 and M24 (P = .001). No significant changes were noted in lumbar spine BMD. The percentage of changes in the femoral neck and the total hip BMD from baseline to M24 positively correlated with postoperative excess weight loss (r = .352, P = .045, and r = .416, P = .018, respectively).

CONCLUSION

Despite notable weight loss, women who underwent SG experienced significant bone loss at the total hip and femoral neck more than 2 years postoperatively. Future studies should investigate intervention strategies to attenuate skeletal deterioration after SG.

Environmental Factors That Affect Parathyroid Hormone and Calcitonin Levels

Calciotropic hormones, parathyroid hormone (PTH) and calcitonin are involved in the regulation of bone mineral metabolism and maintenance of calcium and phosphate homeostasis in the body. Therefore, an understanding of environmental and genetic factors influencing PTH and calcitonin levels is crucial. Genetic factors are estimated to account for 60% of variations in PTH levels, while the genetic background of interindividual calcitonin variations has not yet been studied. In this review, we analyzed the literature discussing the influence of environmental factors (lifestyle factors and pollutants) on PTH and calcitonin levels. Among lifestyle factors, smoking, body mass index (BMI), diet, alcohol, and exercise were analyzed; among pollutants, heavy metals and chemicals were analyzed. Lifestyle factors that showed the clearest association with PTH levels were smoking, BMI, exercise, and micronutrients taken from the diet (vitamin D and calcium). Smoking, vitamin D, and calcium intake led to a decrease in PTH levels, while higher BMI and exercise led to an increase in PTH levels. In terms of pollutants, exposure to cadmium led to a decrease in PTH levels, while exposure to lead increased PTH levels. Several studies have investigated the effect of chemicals on PTH levels in humans. Compared to PTH studies, a smaller number of studies analyzed the influence of environmental factors on calcitonin levels, which gives great variability in results. Only a few studies have analyzed the influence of pollutants on calcitonin levels in humans. The lifestyle factor with the clearest relationship with calcitonin was smoking (smokers had increased calcitonin levels). Given the importance of PTH and calcitonin in maintaining calcium and phosphate homeostasis and bone mineral metabolism, additional studies on the influence of environmental factors that could affect PTH and calcitonin levels are crucial.

Risedronate use to attenuate bone loss following sleeve gastrectomy: Results from a pilot randomized controlled trial

The purpose of this study was to explore the efficacy of 150 mg once monthly oral risedronate use in the prevention of sleeve gastrectomy (SG) associated bone loss. Twenty-four SG patients (56 ± 7 years, 83% female, 21% black) were randomized to risedronate or placebo for 6 months, with an optional 12-month assessment. Outcome measures included 6 (n = 21) and 12 (n = 14) month change in dual energy x-ray absorptiometry-acquired regional areal bone mineral density (aBMD). Six-month treatment effect estimates [mean (95% CI)] revealed significant between group aBMD differences at the femoral neck [risedronate: +0.013 g/cm² (-0.021, 0.046) vs. placebo: -0.041 g/cm² (-0.067, -0.015)] and lumbar spine [risedronate: +0.028 g/cm² (-0.006, 0.063) vs. placebo: -0.029 g/cm² (-0.054, -0.004)]; both p ≤ 0.02. When followed postoperatively to 12 months, differential aBMD treatment effects were observed at the total hip [risedronate: -0.035 g/cm² (-0.061, -0.009) vs. placebo: -0.072 g/cm² (-0.091, -0.052)] and lumbar spine [risedronate: +0.012 g/cm² (-0.038, 0.063) vs. placebo: -0.052 g/cm² (-0.087, -0.017)]; both p < 0.05. Preliminary treatment effect estimates signal 6 months of risedronate use may be efficacious in reducing aBMD loss at the axial skeleton post-SG, with benefit largely maintained throughout the 1-year postoperative period. Confirmatory data from an adequately powered trial are needed.

Rates, Risks, and Time to Fracture in Patients Undergoing Laparoscopic Vertical Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass

Objective

To assess the rates, risks, and time to fracture in patients undergoing laparoscopic vertical sleeve gastrectomy (VSG) versus those undergoing Roux-en-Y gastric bypass (RYGB).

Summary Background Data

Metabolic and bariatric surgery has been implicated in significant bone loss and may increase fracture risk. Preoperative patient characteristics that might impact fracture risk and the time to fractures have not been established. Furthermore, the patient characteristics that might impact fracture risk and the time to fractures by surgical approach are unknown.

Methods

This population-based retrospective cohort analysis used Humana claims data from January 1, 2007 to March 31, 2017, and included 4073 patients undergoing laparoscopic RYGB and VSG as a first surgical intervention for weight loss. The primary outcomes were the incidence of fractures (Humeral, Radial or Ulnar, Pelvic, Hip, and Vertebral) within 48 months after laparoscopic VSG versus RYGB and days to these fractures.

Results

An analysis of total fractures (odds ratio [OR] 0.53; 95% confidence interval [CI], 0.38-0.73), vertebral fractures (OR 0.61; 95% CI, 0.38-0.99), hip fractures (OR 0.36; 95% CI, 0.15-0.84), and humeral fractures (OR 0.44; 95% CI, 0.22-0.90) demonstrated a reduction in fracture risk in patients undergoing VSG versus RYGB. Furthermore, postmenopausal status was independently associated with increased odds of total fractures and hip fractures (OR 2.18; 95% CI, 1.06-4.50; OR 5.83; 95% CI, 1.16-29.27; respectively). Likewise, osteoporosis at the time of surgery was associated with increased odds of total fractures (OR 1.61; 95% CI, 1.09-2.37), vertebral fractures (OR 2.01; 95% CI, 1.19-3.39), and hip fractures (OR 2.38; 95% CI, 1.19-4.77). Except for a significantly decreased odds of vertebral fractures in osteoporotic patients undergoing VSG versus RYGB (OR 0.41; 95% CI, 0.18-0.95), osteoporotic or postmenopausal status at the time of surgery was not found to increase odds of fracture depending on surgical intervention. However, time to fracture (total) and for all site-specific fractures, except for pelvic fractures, was significantly reduced in postmenopausal women undergoing RYGB versus VSG. Time to fracture (total) and for all site-specific fractures except pelvic and radial or ulnar fractures was significantly reduced in osteoporotic patients undergoing RYGB versus VSG.

Conclusions and Relevance

Though bariatric surgery is associated with several health-related benefits, increased fracture risk is an important factor to discuss with patients undergoing bariatric surgery. Bariatric surgery strategy, RYGB versus VSG, carries a differential risk of fracture, with RYGB carrying a higher risk of fracture and decreased time to fracture. Furthermore, patients who are postmenopausal or osteoporotic at the time of surgery carry an increased risk of total fractures, independent of bariatric surgery strategy. Being mindful of patient-specific fracture risk after bariatric surgery may help anticipate, identify, and prevent fractures.