Two-Year Nutrition Data in Terms of Vitamin D, Vitamin B12, and Albumin After Bariatric Surgery and Long-term Fracture Data Compared with Conservatively Treated Obese Patients: a Retrospective Cohort Study

Modification of bone architecture following sleeve gastrectomy: a five-year follow-up

Bariatric surgery induces a decrease in areal BMD (aBMD), but the long-term effect on trabecular and cortical volumetric BMD (vBMD) has not been well assessed. The main aim of this 5-yr longitudinal study was to investigate the changes following sleeve gastrectomy (SG) in aBMD, bone turnover markers, and trabecular and cortical vBMD. Forty-five patients with obesity were assessed before and 1, 2, and 5 yr after SG. Trabecular and cortical vBMD, cortical thickness, and structural parameters were assessed by 3D-Shaper software at the hip. Values of bone turnover markers peaked after 1 yr and decreased after 2 and 5 yr, but without returning to baseline values. aBMD decreased mostly at the femoral neck (-9.7%) and total hip (-10.7%) over the 5 yr, with the greatest loss occurring at 1 yr (-5.9% and -6.3%, respectively). A similar profile of decrease was observed for integral hip vBMD with significant decreases of 6.6%, 7.7%, and 10.7% after 1, 2, and 5 yr, mainly due to a reduction in the trabecular (10.5%, 12.0%, and 17.2%, respectively) rather than cortical (1.4%, 1.9%, and 2.9%, respectively) component. A modest decrease in mean cortical thickness (2.5%, 2.8%, and 3.9%, respectively) and an alteration in the structural parameters were concomitantly observed. Older age and greater body weight loss were the factors most associated with an increased loss of aBMD and vBMD. In conclusion, the study demonstrates that SG induces not only an alteration in bone turnover and aBMD, but also a reduction in vBMD at the hip, predominantly due to trabecular component deterioration as determined by 3D-Shaper software. The maintenance of bone deterioration for at least 5 yr-ie, after 4 yr of relative body weight stabilization or minimal weight regain-suggests the need for a therapeutic approach to preserve bone health in patients who undergo SG.

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.

Bariatric Surgery and Metabolic Status

Background and Objectives: Obesity is associated with numerous co-morbidities, including dyslipidemia, insulin resistance and diabetes mellitus. Bariatric surgery is the mainstay of treatment for obesity as the only method with confirmed long-term effects in weight reduction and the remission of comorbidities. Postoperative recommendations leading to changes in dietary habits and changes in digestion and absorption in the gastrointestinal tract after bariatric surgery may additionally influence the levels of laboratory parameters that reflect the metabolic and nutritional status. The purpose of the study was to analyze the possible influence of changes in dietary habits after bariatric surgery on those laboratory results that reflect the metabolic and nutritional status. Materials and Methods: This was a retrospective study of 88 patients with a history of bariatric surgery. Data were gathered from before the surgery and at 6 months after the surgery and included diet structure and selected laboratory parameters reflecting the metabolic and nutritional status, i.e., levels of fasting glucose, glycated hemoglobin, cholesterol, low- and high-density lipoproteins, triglycerides, alanine and aspartate aminotransferases, proteins, ferrum, ferritin, vitamin B12, folic acid, vitamin D and calcium, the red blood cell count and the hematocrit. Results: Postoperative festive glucose levels were reduced by 14% and were more significant in patients after Roux-en-Y gastric bypass. There was an increase of 22% in concentrations of high-density lipoproteins. Triglyceride concentrations were reduced by 32%. Aminotransferase levels decreased by 43% for alanine aminotransferase and by 14% for aspartate aminotransferase. Among the changes in dietary habits, post-bariatric patients had a reduced consumption of red meat and an increased consumption of fish, milk and dairy products and wholegrain products. Vitamin D and ferrum levels were higher after the surgery, whereas vitamin B12 and folic acid levels remained unchanged. Conclusions: Improved dietary habits of patients after bariatric surgery may lead to changes in laboratory parameters that reflect the ameliorated metabolic and nutritional status of patients after bariatric surgery.

Changes in Serum Concentration of Antidepressants After Bariatric Surgery and Recommendations for Postbariatric Surgery Antidepressant Therapy

BACKGROUND

Bariatric surgery affects the absorption of medications including antidepressants, but data regarding these effects are limited.

OBJECTIVES

Our objectives were to review publicly available data regarding changes in antidepressant serum concentration following bariatric surgery in order to develop medication dosing recommendations in this patient population.

METHODS

A comprehensive literature review was performed utilizing key search terms in Pubmed. Additional data were retrieved from the Food and Drug Administration and DrugBank Online resources.

RESULTS

A total of twelve published articles were included in addition to the publicly available data from the Food and Drug Administration and DrugBank. The serum concentration of antidepressants following bariatric surgery demonstrated considerable variability between and within drug classes due to unique pharmacokinetic features, drug preparation, and formulation. Recommendations were developed from published data regarding changes in serum concentration and drug-specific pharmacokinetic data.

CONCLUSIONS

To our knowledge, this is the first study to propose medication dose-adjustment recommendations for patients on antidepressants undergoing bariatric surgery. We were limited by the relatively small amount of data available and recommend monitoring patients and use of clinical judgment along with this guidance.

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.

The prognostic value of retinol binding protein in geriatric hip fractures after surgeries: A propensity score matching and 1-year follow-up study

BACKGROUND

We aimed to explore the predictive value of retinol binding protein (RBP) for outcomes of hip fractures.

METHODS

Patients with hip fractures who underwent hip surgeries between December 2017 and February 2021 and met the inclusion criteria were analyzed. Propensity score matching was used to reduce the bias of co-factors and ROC curves based on matched populations were created to determine the optimal cutoff point of RBP. The outcomes between patients with low levels of RBP and high levels of RBP were compared.

RESULTS

Four hundred eighty patients were enrolled in this study and 69 patients died within one year. After a 1:1 PSM, patients with more than 1-year survival had significantly higher RBP (p = 0.013) than those who died within one year, as well as patients divided by 6-months survival (p = 0.012). Logistics analysis showed that low RBP may be an independent risk factor for 3-month survival, 6-month survival, 1-year survival, and 3-month free walking ability.

CONCLUSION

RBP may be associated with the survival and 3-month walking abilities of patients with hip fractures.

Bariatric Surgery in Adolescents with Obesity: Long-Term Perspectives and Potential Alternatives

BACKGROUND

Severe obesity among adolescent shows a worrisome trend in regard to its increasing prevalence and poses a great challenge for treatment. Conservative measures have modest effects on weight loss, usually fail in achieving a sustainable weight loss and resolution of comorbidities. This has led to greater utilization of bariatric surgery (BS) that offers a fast reduction in body mass index with little perioperative complications. Despite the increasing utilization of BS, data are still insufficient, regarding their long-term outcome in adolescents. We review short- and long-term effects of BS and their implications on bone health and nutritional deficiencies in adolescents. In addition, we discuss possible pharmaceutical alternatives.

SUMMARY

BS results in a substantial weight loss of roughly 37% in the first-year post-operation and is superior to conservative measures in resolution of metabolic comorbidities. BS significantly improves health-related quality of life. Longer follow-up (F/U) shows weight regain in 50% of patients. Furthermore, reduced bone mass and nutritional deficiencies were reported in up to 90% of patients. Most recently, alternative to BS became more relevant with approval of GLP-1 analogues use in adolescents. GLP-1 analogues are potent enough to induce moderate clinically meaningful weight loss and improvement of metabolic component.

KEY MESSAGES

We conclude that obese adolescents without major obesity-related complications may benefit from pharmacological interventions with lifestyle modification. We advise considering BS as treatment approach in adolescents with severe obesity and major obesity-related complications with proper preoperative preparation and postoperative F/U in excellence centers.

Fracture risk following bariatric surgery: a systematic review and meta-analysis

Bariatric surgery may negatively impact bone health. We aimed to compare fracture risk following bariatric surgery by type (malabsorptive, restrictive), or to non-surgical weight loss, or to controls with obesity. We systematically searched four databases from inception until October 2020. We included observational and interventional studies on adults. We screened articles and abstracted data in duplicate and independently and assessed the risk of bias. We conducted random-effects model meta-analyses (Review Manager v5.3), to calculate the relative risk of any or site-specific fracture (CRD42019128536). We identified four trials of unclear-to-high risk of bias and 15 observational studies of fair-to-good quality. Data on fracture risk following bariatric surgery compared to medical weight loss is scarce and limited by the small number of participants. In observational studies, at a mean/median post-operative follow-up > 2 years, the relative risk of any fracture was 45% (p < 0.001) and 61% (p = 0.04) higher following malabsorptive procedures compared to obese controls and restrictive procedures, respectively, with moderate to high heterogeneity. Site-specific relative fracture risk (hip and wrist) was one- to two-folds higher post malabsorptive procedures compared to obese controls or restrictive procedures. The risks of any and of site-specific fracture were not increased following restrictive procedures compared to obese controls. Fracture risk seems to increase following malabsorptive bariatric surgeries, at a mean/median follow-up > 2 years. The risk is not increased with restrictive surgeries. The available evidence has several limitations. A prospective and rigorous long-term follow-up of patients following bariatric surgery is needed for a better assessment of their fracture risk with aging.

Vitamin B Complex Deficiency After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy-a Systematic Review and Meta-Analysis

Bariatric surgery, although an effective method, still has complications, like nutritional deficiencies. Our aim was to summarize the evidence on the frequency of complex B vitamin deficiencies in studies comparing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). We included 25 studies for qualitative synthesis and 21 studies for quantitative synthesis. Relevant data was extracted, including proportion of patients with deficiency and mean serum vitamin values in 3 different timeframes. B12 and folate were the most prevalent deficiencies. B12 deficiency was more common after RYGB and folate serum mean levels were higher after RYGB. SG causes less nutrient deficiency and is therefore a better technique from this point of view. More studies are needed on B2, B3, and B6 vitamins to draw better conclusions.

Effects of Gastric Bypass and Sleeve Gastrectomy on Bone Mineral Density and Bone Turnover Markers: A Systematic Review and Meta-Analysis

BACKGROUND

There is a growing interest in the post-operative bone-related effects of bariatric surgery. However, little is known about the comparative effects of the most commonly performed bariatric procedures, namely Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

OBJECTIVES

To systematically assess the differences in areal bone mineral density (aBMD) and biochemical and hormonal markers of bone metabolism among patients undergoing RYGB and SG.

METHODS

We conducted a systematic review and meta-analysis of studies aBMD at different sites, as well as bone-specific alkaline phosphatase (BALP), 25-OH-vitamin D, calcium and parathyroid hormone (PTH) after RYGB and SG.

RESULTS

Fourteen studies were included (717 patients, 50.63% in the RYGB arm). Based on data collected at 1 year, 2 years and > 2 years, there were no significant differences in aBMD measurements at the total hip, lumbar spine, femoral neck, and the whole body with no statistical heterogeneity among different comparisons. Patients in the RYGB group showed significantly higher concentrations of BALP at 1 year (SMD = 0.52, 95%CI, 0.23-0.81, p = 0.0004) and PTH at > 2 years of follow-up (SMD = 0.68, 95%CI, 0.31-1.05, p = 0.0003) compared to the SG group.

CONCLUSION

There were no significant differences in aBMD measurements at the hip, lumbar spine, femoral neck, and the total body following RYGB and SG procedures. However, BALP and PTH concentrations were significantly higher after RYGB surgeries compared to SG. Attention should be paid to patients undergoing RYGB to prevent the expected skeletal fragility over time.

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.

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.

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

Haemoglobin and Hematinic Status Before and After Bariatric Surgery over 4 years of Follow-Up

PURPOSE

Bariatric surgery is associated with deficiencies of vitamins and minerals, and patients are routinely advised supplements postoperatively. We studied prevalence of vitamin B12, folate and iron deficiencies and anaemia before and after bariatric surgery over 4 years of follow-up.

MATERIALS AND METHODS

We performed a retrospective cohort analysis of 353 people with obesity, including 257 (72.8%) women, who underwent gastric bypass (252, 71.4%) or sleeve gastrectomy (101, 28.6%) at our National Health Service bariatric centre in Northwest England.

RESULTS

At baseline, mean (standard error) age was 46.0 (0.6) years, body mass index 53.1 (0.4) kg/m2, serum vitamin B12 400.2 (16.4) pg/L, folate 7.7 (0.2) μg/L, iron 12.0 (0.3) μmol/L, ferritin 118.3 (8.4) μg/L and haemoglobin 137.9 (0.8) g/L. Frequency of low vitamin B12 levels reduced from 7.5% preoperatively to 2.3% at 48 months (P < 0.038). Mean folate levels increased from baseline to 48 months by 5.3 μg/L (P < 0.001) but frequency of low folate levels increased from 4.7% preoperatively to 10.3% (P < 0.048). Ferritin levels increased from baseline to 48 months by 51.3 μg/L (P < 0.009). Frequency of low ferritin levels was greater in women (39.1%) than in men (8.9%) at baseline (P < 0.001) and throughout the study period. Haemoglobin was low in 4.6% of all patients at baseline with no significant change over the study period.

CONCLUSION

There were notable rates of haematinic insufficiencies in bariatric surgical candidates preoperatively. Our study lends further support to regular supplementation with vitamin B12, folic acid, and iron in people undergoing bariatric surgery.

MANAGEMENT OF ENDOCRINE DISEASE: Bone complications of bariatric surgery: updates on sleeve gastrectomy, fractures, and interventions

Despite well recognized improvements in obesity-related comorbidities, increasing evidence implicates bariatric surgery in the onset of adverse skeletal health outcomes. The purpose of this review is to provide a focused update in three critical areas: (i) emergent data on sleeve gastrectomy and bone loss, (ii) evidence linking bariatric surgery to incident fracture, and (iii) intervention strategies designed to mitigate surgical bone loss. Better understanding of these issues will inform our treatment of skeletal health for patients planning bariatric surgery.

Risedronate to Prevent Bone Loss After Sleeve Gastrectomy: Study Design and Feasibility Report of a Pilot Randomized Controlled Trial

Mounting evidence implicates bariatric surgery as a cause of increased skeletal fragility and fracture risk. Bisphosphonate therapy reduces osteoporotic fracture risk and may be effective in minimizing bone loss associated with bariatric surgery. The main objective of this pilot randomized controlled trial (RCT; Clinical Trial No. NCT03411902) was to determine the feasibility of recruiting, treating, and following 24 older patients who had undergone sleeve gastrectomy in a 6 month RCT examining the efficacy of 150‐mg once‐monthly risedronate (versus placebo) in the prevention of surgical weight‐loss–associated bone loss. Feasibility was defined as: (i) >30% recruitment yield, (ii) >80% retention, (iii) >80% pills taken, (iv) <20% adverse events (AEs), and (v) >80% participant satisfaction. Study recruitment occurred over 17 months. Seventy participants were referred, with 24 randomized (34% yield) to risedronate (n = 11) or placebo (n = 13). Average age was 56 ± 7 years, 83% were female (63% postmenopausal), and 21% were black. The risedronate group had a higher baseline BMI than the placebo group (48.1 ± 7.2 versus 41.9 ± 3.8 kg/m²). The 10‐year fracture risk was low (6.0% major osteoporotic fracture, 0.4% hip fracture); however, three individuals (12.5%, all risedronate group) were osteopenic at baseline. Twenty‐one participants returned for 6‐month follow‐up testing (88% retention) with all (n = 3) loss to follow‐up occurring in the risedronate group. Average number of pills taken among completers was 5.9 ± 0.4 and 6.0 ± 0.0 in the risedronate and placebo groups, respectively (p = 0.21), with active participants taking >80% of allotted pills. Five AEs (3.7% AE rate) were reported; one definitely related, four not related, and none serious. All participants reported high satisfaction with participation in the study. Use of bisphosphonates as a novel therapeutic to preserve bone density in patients who had undergone a sleeve gastrectomy appears feasible and well‐tolerated. Knowledge gained from this pilot RCT will be used to inform the design of an appropriately powered trial.

Clinical Trial Registration

http://clinicaltrials.gov/show/NCT03411902. Weight Loss With Risedronate for Bone Health. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Impact of sleeve gastrectomy on hip structural analysis in adolescents and young adults with obesity

BACKGROUND

Sleeve gastrectomy (SG), the most commonly performed metabolic and bariatric surgery, is associated with reductions in areal bone mineral density at multiple sites, and changes in bone structure at the distal radius and tibia without reductions in strength estimates at these peripheral sites. Data are lacking regarding effects on hip strength estimates.

OBJECTIVE

To evaluate effects of SG on measures of hip structural analysis in adolescents and young adults over 12 months using dual-energy x-ray absorptiometry.

SETTINGS

Translational and Clinical Research Center.

METHODS

We enrolled 48 youth 14- to 22-years old with moderate-to-severe obesity; 24 underwent SG and 24 controls were followed without surgery (18 females, 6 males in each group). Hip structure was assessed using dual-energy x-ray absorptiometry at baseline and 12 months. Analyses are adjusted for age, sex, race, and the baseline bone measure.

RESULTS

The SG group lost 25.9% weight versus .3% in controls. Compared with controls, SG had reductions in narrow neck, intertrochanteric and femoral shaft bone mineral density Z-scores (P ≤ .012). Furthermore, SG had greater reductions in narrow neck and intertrochanteric region (but not femoral shaft) cross-sectional area, cortical thickness, cross-sectional moment of inertia and section modulus, and increases in buckling ratio (P ≤ .039). Differences were attenuated after adjusting for 12-month body mass index change. At 12 months, differences were minimal after adjusting for age, sex, race, and weight.

CONCLUSIONS

Over 12 months, SG had negative effects at the narrow neck and intertrochanteric regions of the hip, but not the femoral shaft. Reduced body mass index may compensate for these deleterious effects on bone.

Psychopharmacological Medication Has No Influence on Vitamin Status After Bariatric Surgery in Long-term Follow-up

Context

A substantial number of patients undergoing bariatric surgery are prescribed psychopharmacological medication. However, the impact of concomitant psychopharmacological medication on the frequency of relevant vitamin deficiencies in postoperative follow-up is not known.

Methods

Five hundred twenty-four patients with obesity who underwent bariatric surgery (January 2004 to September 2018) with follow-up of at least 12 months, were included in retrospective analysis. Postoperative follow-up visits between January 2015 and September 2019 were analyzed. Anthropometric and laboratory data were analyzed at the first documented follow-up visit after on average 39.5 ± 37.3 months and at every following visit during the observation period. Patients with prescribed psychopharmacological drugs (PD) were compared with patients without (control group, CON).

Results

Psychopharmacological medication was documented in 25% (132) of patients. In 59 patients documented prescription of more than one psychiatric drug was found, whereas psychopharmacological monotherapy was found in 73 patients. Frequencies of vitamin deficiencies were comparable between PD and CON (vitamin A: p = 0.852; vitamin D: p = 0.622; vitamin E: p = 0.901; folic acid: p = 0.941). Prevalence of vitamin B₁₂ deficiency was rare (6% CON, 1% PD) but was significantly higher in CON (p = 0.023). A comparison of CON and POLY also showed no significant differences between the groups concerning prevalence of vitamin deficiencies.

Conclusions

Intake of psychopharmacological medication is highly prevalent in patients after bariatric surgery. Patients with psychopharmacological medication, who participate in structured follow-up care after bariatric surgery, are not at higher risk for vitamin deficiencies compared with controls.

Bone outcomes following sleeve gastrectomy in adolescents and young adults with obesity versus non-surgical controls

BACKGROUND

Sleeve gastrectomy is the most commonly performed weight loss surgery in adolescents with moderate-to-severe obesity. While studies in adults have reported on the deleterious effects of gastric bypass surgery on bone structure and strength estimates, data are lacking for the impact of sleeve gastrectomy on these measures in adolescents.

OBJECTIVE

To evaluate the impact of sleeve gastrectomy on bone outcomes in adolescents and young adults over 12 months using dual energy X-ray absorptiometry (DXA) and high resolution peripheral quantitative computed tomography (HRpQCT).

PARTICIPANTS AND METHODS

We enrolled 44 youth 14-22 years old with moderate to severe obesity; 22 underwent sleeve gastrectomy and 22 were followed without surgery (16 females and 6 males in each group). At baseline and 12 months, DXA was used to assess areal bone mineral density (aBMD), HRpQCT of the distal radius and tibia was performed to assess bone geometry, microarchitecture and volumetric BMD (vBMD), and finite element analysis to assess strength estimates (stiffness and failure load). These analyses were adjusted for age, sex, race and the bone measure at baseline. Fasting blood samples were assessed for calcium, phosphorus, and 25(OH) vitamin D (25OHD) levels.

RESULTS

Over 12-months, the surgical group lost 27.2% of body weight compared to 0.1% in the non-surgical (control) group. Groups did not differ for changes in 25OHD levels (p = 0.186). Compared to controls, the surgical group had reductions in femoral neck and total hip aBMD Z-scores (p ≤ 0.0006). At the distal tibia, compared to controls, the surgical group had reductions in cortical area and thickness and trabecular number, and increases in trabecular area and separation (p ≤ 0.026). At the distal radius, the surgical group had greater reductions in trabecular vBMD, than controls (p = 0.010). The surgical group had an increase in cortical vBMD at both sites (p ≤ 0.040), possibly from a decrease in cortical porosity (p ≤ 0.024). Most, but not all, differences were attenuated after adjusting for 12-month change in BMI. Groups did not differ for changes in strength estimates over time, except that increases in tibial stiffness were lower in the surgical group (p = 0.044) after adjusting for 12-month change in BMI.

CONCLUSIONS

Over 12 months, weight loss associated with sleeve gastrectomy in adolescents had negative effects on areal BMD and certain HRpQCT parameters. However, bone strength estimates remained stable, possibly because of a simultaneous decrease in cortical porosity and increase in cortical volumetric BMD. Additional research is necessary to determine the relative contribution(s) of weight loss and the metabolic effects of surgery on bone outcomes, and whether the observed effects on bone stabilize or progress over time.

Bone Health Following Bariatric Surgery: An Update

Obesity rates are increasing rapidly, and bariatric surgery is currently the most effective tool for weight loss. Recently, bariatric surgery induced bone loss has gained attention. Such detrimental effect on bone is multifactorial and causes may include nutrient deficiencies, gut and gonadal hormonal changes, mechanical unloading, loss of lean mass, increased bone marrow fat, and increased risk of fall. This review describes the available evidence on bone loss and fracture risk following bariatric surgery and summarizes the guidelines on the topic. Increased bone resorption starts early postsurgery, and bone markers peak at 1-2 yr. Across studies, the drop in areal bone mineral density is inconsistent at the lumbar spine, while a 2%-5% drop at 6 mo and a 6%-10.5% at 9-12 mo are observed at the total hip. Conversely, studies using quantitative CT showed a 6%-7% decrease in volumetric bone mineral density at the lumbar spine at 6-12 mo postsurgery. These studies also report significant bone loss at the radius and tibia, in addition to alteration in bone microarchitecture. Fracture risk increases 2 yr after surgery, more so following malabsorptive procedures. Fractures were reported at axial, weight bearing sites and at appendicular sites. The available evidence is very heterogeneous, and mostly derived from studies on Roux-en-y gastric bypass in premenopausal women. Data on restrictive procedures is scarce. Our findings suggest that the early postoperative phase represents the "golden window" to intervene and promote bone health. More research is needed to determine the effect of different bariatric procedures on bone, to identify optimal interventions to prevent bone loss and to characterize high risk individuals who should be targeted.

Comparative risk of fracture for bariatric procedures in patients with obesity: A systematic review and Bayesian network meta-analysis

OBJECTIVE

Bariatric surgery (malabsorptive [i.e., biliopancreatic diversion, BPD], restrictive [i.e., sleeve gastrectomy, SG; adjustable gastric banding, AGB] and mixed [i.e., gastric bypass, GB] procedures) has been reported to be associated with an increased risk of fracture; however, which procedure poses the greatest risk of fracture is still controversial. The aim of the current meta-analysis was to investigate the degree of fracture risk after different bariatric procedures.

MATERIAL AND METHODS

Electronic databases, including Medline/PubMed, EMBASE and Cochrane library, were systematically searched from inception to July 11, 2019 with no language restrictions to retrieve randomized controlled trials (RCTs) or cohort studies evaluating the impact of any kind of bariatric surgery on postoperative fractures in patients with obesity. Pairwise meta-analysis and Bayesian network meta-analysis were performed to pool the outcome estimates of interest, including fracture incidence and fracture risk. The values of the surface under the cumulative ranking (SUCRA) probability for fracture risk were calculated and sorted according to the different surgical procedures.

RESULTS

A total of twelve studies published between 2010 and 2019, comprising 159,916 participants with obesity were identified for the analysis. The incidence of fracture increased from 3% (95% confidence interval [CI] 2-4%) in patients with non-surgical intervention (drug treatment, alteration in life style and diet control) to 5% (95% CI 4-7%) in those who had undergone bariatric surgery (pooled relative risk [RR] = 1.41 95% CI: 1.22-1.63). Network meta-analysis revealed that based on the SUCRA ranking of the different surgical procedures, the malabsorptive procedure had the highest possibility of increased fracture risk in patients with obesity (74.75%), followed by the mixed procedures (73.85%), nonsurgical intervention (43.55%) and the restrictive procedure (7.85%); for different surgery types. The BPD group had the highest possibility of increased fracture risk (99.49%), followed by the GB (74.92%), nonsurgical intervention (44.49%), AGB (26.64%) and SG (4.45%) groups.

CONCLUSIONS

Significant differences exist among different bariatric surgeries impacting on fracture risk. The malabsorptive and mixed procedures, but not the restrictive procedure, increase the postoperative risk of fracture. Considering the weight-reduction effects and fracture risk, the sleeve gastrectomy procedure may be the best choice for patients with obesity, especially those who are susceptible to osteoporosis.

Effects of Laparoscopic Sleeve Gastrectomy on Bone Mineral Density and Bone Metabolism in Chinese Patients with Obesity

OBJECTIVE

Laparoscopic sleeve gastrectomy (LSG) is one of the most effective therapies to treat obesity. Due to a lack of longitudinal research, we explored the changes in BMD and bone metabolism in Chinese patients with obesity before and after LSG.

MATERIALS AND METHODS

A total of 49 obese Chinese patients with obesity were recruited from the Second Xiangya Hospital of Central South University. All patients underwent LSG, and the metabolic indicators were evaluated, including the serum osteocalcin (OC), total-terminal propeptide of type I procollagen (TPINP) and carboxy terminal telopeptide of collagen type I (CTX) levels at baseline and 2, 6 and 12 months postoperatively. Dual energy X-ray absorptiometry (DEXA) was used to measure body composition and BMD before and 12 months after LSG.

RESULTS

The body mass index (BMI) significantly decreased at 12 months postoperatively, and no patients developed osteoporosis. The BMD of femoral neck and total hip significantly decreased from the baseline to 12 months postoperatively, while the BMD of lumbar spine did not change significantly. The OC, TPINP and CTX levels significantly increased at 12 months postoperatively. The excess BMI loss (EBMIL) was positively related while the reduction in visceral adipose tissue (VAT) mass was negatively related to the decreases in BMD of the femoral neck and total hip at 12 months postoperatively. The increase in OC was negatively correlated with the decrease in BMD of the femoral neck, while the increase in TPINP was positively correlated with the decrease in BMD of total hip.

CONCLUSION

Based on the 12-month follow-up results, the BMD of the femoral neck and total hip was decreased in Chinese patients with obesity after LSG, while bone remodelling was active. This finding suggested that weight loss, a decrease in the VAT mass and an increase in bone remodelling may be correlated with a reduction in BMD.