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Duan L, Wang Y, Cheng L, Wang J. Changes in Nutritional Outcomes After Roux-en-Y Gastric Bypass: A Systematic Review and Meta-Analysis. Obes Surg 2024; 34:2116-2129. [PMID: 38662252 DOI: 10.1007/s11695-024-07232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Bariatric surgery (BS) is the most effective treatment for severe obesity and it has beneficial effects on glycemic control and metabolism outcomes. However, the effects of BS on nutritional outcomes are controversial. Therefore, we aimed to evaluate the changes in several nutritional outcomes after Roux-en-Y gastric bypass (RYGB). METHODS A comprehensive search was performed using the following databases: PubMed, Embase, Web of Science, Cochrane Library, WanFang and Chinese National Knowledge Infrastructure. The following outcomes were evaluated: vitamin A, 25-hydroxyvitamin D [25(OH)D], calcium, phosphorus, parathormone (PTH), iron, ferritin, vitamin B12, folate, and zinc. The pooled outcomes were expressed as standard mean difference (SMD) and 95% confidence interval (CI) using a random effects model. RESULTS Fifty-six studies including 5645 individuals with obesity met the inclusion criteria. Serum 25(OH)D (SMD = 0.78, 95%CI 0.38 to 1.20, P < 0.001), phosphorus (SMD = 0.48, 95%CI 0.22 to 0.74, P < 0.001), PTH (SMD = 0.35, 95%CI 0.11 to 0.59, P = 0.005), vitamin B12 (SMD = 1.11, 95%CI 0.41 to 1.80, P = 0.002), and folate (SMD = 1.53, 95%CI 0.77 to 2.28, P < 0.001) significantly increased after RYGB compared with the baseline. Serum ferritin (SMD = - 1.67, 95%CI - 2.57 to - 0.77, P < 0.001), vitamin A (SMD = - 0.64, 95%CI - 0.99 to - 0.29, P < 0.001), and plasma zinc (SMD = - 0.58, 95%CI - 1.09 to - 0.06, P = 0.027) significantly decreased after RYGB. No significant changes in serum calcium (SMD = - 0.14, 95%CI - 0.40 to 0.11, P = 0.219) and iron (SMD = 0.26, 95%CI - 0.11 to 0.64, P = 0.165) were observed after RYGB. CONCLUSIONS Despite the increased levels of 25(OH)D, phosphorus, vitamin B12 and folate, this meta-analysis revealed the unfavorable nutritional consequences after RYGB.
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Affiliation(s)
- Leizhen Duan
- Department of Medical Services, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, Henan, China
| | - Yan Wang
- Public Health and Preventive Medicine Teaching and Research Center, Henan University of Chinese Medicine, Zhengzhou, China
| | - Lingling Cheng
- Huajing Town Community Health Service Center, Xuhui District, Shanghai, 200231, China
| | - Jun Wang
- Department of Clinical Nutrition, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Tongbai North Road 16, Zhengzhou, 450001, Henan, China.
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Nie M, Zhang J, Bal M, Duran C, An SW, Zigman JM, Baum M, Hiremath C, Marciano DK, Wolf MTF. Ghrelin enhances tubular magnesium absorption in the kidney. Front Physiol 2024; 15:1363708. [PMID: 38638279 PMCID: PMC11024433 DOI: 10.3389/fphys.2024.1363708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 03/07/2024] [Indexed: 04/20/2024] Open
Abstract
Osteoporosis after bariatric surgery is an increasing health concern as the rate of bariatric surgery has risen. In animal studies mimicking bariatric procedures, bone disease, together with decreased serum levels of Ca2+, Mg2+ and the gastric hormone Ghrelin were described. Ghrelin regulates metabolism by binding to and activating the growth hormone secretagogue receptor (GHSR) which is also expressed in the kidney. As calcium and magnesium are key components of bone, we tested the hypothesis that Ghrelin-deficiency contributes to osteoporosis via reduced upregulation of the renal calcium channel TRPV5 and the heteromeric magnesium channel TRPM6/7. We expressed GHSR with TRPV5 or TRPM6/7 channel in HEK293 cells and treated them with purified Ghrelin. Whole-cell current density was analyzed by patch-clamp recording. Nephron-specific gene expression was performed by tubular microdissection followed by qPCR in wild-type (WT) mice, and immunofluorescent imaging of GHSR-eGFP mice. Tubular magnesium homeostasis was analyzed in GHSR-null and WT mice at baseline and after caloric restriction. After Ghrelin exposure, whole-cell current density did not change for TRPV5 but increased for TRPM6/7 in a dose-dependent fashion. Applying the Ghrelin-mimetic (D-Trp7, Ala8,D-Phe10)-α-MSH (6-11) amide without and with the GHSR antagonist (D-Lys3)-GHRP6, we confirmed the stimulatory role of Ghrelin towards TRPM6/7. As GHSR initiates downstream signaling via protein kinase A (PKA), we found that the PKA inhibitor H89 abrogated TRPM6/7 stimulation by Ghrelin. Similarly, transfected Gαs, but not the Gαs mutant Q227L, nor Gαi2, Gαq, or Gα13 upregulated TRPM6/7 current density. In microdissected TALs and DCTs similar levels of GHSR mRNA were detected. In contrast, TRPM6 mRNA was expressed in the DCT and also detected in the TAL at 25% expression compared to DCT. Immunofluorescent studies using reporter GHSR-eGFP mice showed a strong eGFP signal in the TAL but surprisingly displayed no eGFP signal in the DCT. In 3-, 6-, and 9-month-old GHSR-null and WT mice, baseline serum magnesium was not significantly different, but 24-h urinary magnesium excretion was elevated in 9-month-old GHSR-null mice. In calorically restricted GHSR-null mice, we detected excess urinary magnesium excretion and reduced serum magnesium levels compared to WT mice. The kidneys from calorically restricted WT mice showed upregulated gene expression of magnesiotropic genes Hnf1b, Cldn-16, Cldn-19, Fxyd-2b, and Parvalbumin compared to GHSR-null mice. Our in vitro studies show that Ghrelin stimulates TRPM6/7 via GHSR and Gαs-PKA signaling. The murine studies are consistent with Ghrelin-GHSR signaling inducing reduced urinary magnesium excretion, particularly in calorically restricted mice when Ghrelin levels are elevated. This effect may be mediated by Ghrelin-upregulation of TRPM6 in the TAL and/or upregulation of other magnesiotropic genes. We postulate that rising Ghrelin levels with hunger contribute to increased renal Mg2+ reabsorption to compensate for lack of enteral Mg2+ uptake.
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Affiliation(s)
- Mingzhu Nie
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Jing Zhang
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Manjot Bal
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Claudia Duran
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sung Wan An
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
| | - Jeffrey M. Zigman
- Department of Internal Medicine, Center for Hypothalamic Research, UTSW Medical Center, Dallas, TX, United States
| | - Michel Baum
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Chitkale Hiremath
- Department of Internal Medicine, Nephrology, and Department of Cell Biology, UTSW Medical Center, Dallas, TX, United States
| | - Denise K. Marciano
- Department of Internal Medicine, Nephrology, and Department of Cell Biology, UTSW Medical Center, Dallas, TX, United States
| | - Matthias T. F. Wolf
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
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Changes in the Bone Mineral Density after Sleeve Gastrectomy vs. Roux-En-Y Gastric Bypass 2 Years after Surgery. Nutrients 2022; 14:nu14153056. [PMID: 35893910 PMCID: PMC9329775 DOI: 10.3390/nu14153056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Trends in insulin-like growth factor-1 levels after bariatric surgery: a systematic review and meta-analysis. Int J Obes (Lond) 2022; 46:891-900. [PMID: 35034953 DOI: 10.1038/s41366-021-01051-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/29/2021] [Accepted: 12/10/2021] [Indexed: 11/08/2022]
Abstract
According to studies, there are many inconsistencies in how IGF-1 levels change after bariatric surgery compared to before surgery, as well as its effects. These discrepancies can be attributed to various factors such as age, body mass index (BMI), and duration of intervention. Therefore, the aim of this study was to evaluate the level of insulin-like growth factor-1 (IGF-1) after bariatric surgery. A systematic review and meta-analysis based on the PRISMA guidelines was conducted from inception until 2021. From 1871 articles initially selected, 24 studies with 28 treatment arms met the eligible criteria and were included. Pooled findings from the random-effects model indicated that IGF-1 levels increased significantly [weighted mean difference (WMD) = 8.84 ng/ml; 95% confidence interval (CI) 0.30-17.39; p = 0.043] after bariatric surgery compared to before surgery. No significant heterogeneity was noted among the studies (Cochran Q test, p = 0.90, I2 = 0.0%). In subgroup analysis, bariatric surgery significantly increased IGF-1 levels at age <40 years but not at age ≤40 years. Bariatric surgery is capable of increasing the IGF-1 levels compared to the period prior to surgery but with a modest clinical magnitude.
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Mele C, Caputo M, Ferrero A, Daffara T, Cavigiolo B, Spadaccini D, Nardone A, Prodam F, Aimaretti G, Marzullo P. Bone Response to Weight Loss Following Bariatric Surgery. Front Endocrinol (Lausanne) 2022; 13:921353. [PMID: 35873004 PMCID: PMC9301317 DOI: 10.3389/fendo.2022.921353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Chiara Mele
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- *Correspondence: Chiara Mele,
| | - Marina Caputo
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
- Division of Endocrinology, University Hospital “Maggiore della Carità”, Novara, Italy
| | - Alice Ferrero
- Division of Endocrinology, University Hospital “Maggiore della Carità”, Novara, Italy
| | - Tommaso Daffara
- Division of Endocrinology, University Hospital “Maggiore della Carità”, Novara, Italy
| | - Beatrice Cavigiolo
- Division of Endocrinology, University Hospital “Maggiore della Carità”, Novara, Italy
| | - Daniele Spadaccini
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Antonio Nardone
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation and Spinal Unit of Pavia Institute, Pavia, and Neurorehabilitation of Montescano Institute, Montescano, PV, Italy
| | - Flavia Prodam
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
- Division of Endocrinology, University Hospital “Maggiore della Carità”, Novara, Italy
| | - Gianluca Aimaretti
- Division of Endocrinology, University Hospital “Maggiore della Carità”, Novara, Italy
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Paolo Marzullo
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
- Istituto Auxologico Italiano, IRCCS, Laboratory of Metabolic Research, S. Giuseppe Hospital, Piancavallo, Italy
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Couch BK, Fourman MS, Shaw JD, Wawrose RA, Talentino SE, Boakye LAT, Donaldson WF, Lee JY. Pre-Operative Bariatric Surgery Imparts An Increased Risk of Infection, Re-Admission and Operative Intervention Following Elective Instrumented Lumbar Fusion. Global Spine J 2021; 13:977-983. [PMID: 33906460 DOI: 10.1177/21925682211011601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To evaluate the impact of bariatric surgery on patient outcomes following elective instrumented lumbar fusion. METHODS A retrospective review of a prospectively collected database was performed. Patients who underwent a bariatric procedure prior to an elective instrumented lumbar fusion were evaluated. Lumbar procedures were performed at a large academic medical center from 1/1/2012 to 1/1/2018. The primary outcome was surgical site infection (SSI) requiring surgical debridement. Secondary outcomes were prolonged wound drainage requiring treatment, implant failure requiring revision, revision secondary to adjacent segment disease (ASD), and chronic pain states. A randomly selected, surgeon and comorbidity-matched group of 59 patients that underwent an elective lumbar fusion during that period was used as a control. Statistical analysis was performed using Student's two-way t-tests for continuous data, with significance defined as P < .05. RESULTS Twenty-five patients were identified who underwent bariatric surgery prior to elective lumbar fusion. Mean follow-up was 2.4 ± 1.9 years in the bariatric group vs. 1.5 ± 1.3 years in the control group. Patients with a history of bariatric surgery had an increased incidence of SSI that required operative debridement, revision surgery due to ASD, and a higher incidence of chronic pain. Prolonged wound drainage and implant failure were equivalent between groups. CONCLUSION In the present study, bariatric surgery prior to elective instrumented lumbar fusion was associated increased risk of surgical site infection, adjacent segment disease and chronic pain when compared to non-bariatric patients.
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Affiliation(s)
- Brandon K Couch
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Mitchell S Fourman
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Jeremy D Shaw
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Richard A Wawrose
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | | | - Lorraine A T Boakye
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - William F Donaldson
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
| | - Joon Y Lee
- Department of Orthopaedic Surgery, 6595University of Pittsburgh Medical Center, PA, USA
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Jensen VFH, Mølck AM, Dalgaard M, McGuigan FE, Akesson KE. Changes in bone mass associated with obesity and weight loss in humans: Applicability of animal models. Bone 2021; 145:115781. [PMID: 33285255 DOI: 10.1016/j.bone.2020.115781] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/05/2020] [Accepted: 11/27/2020] [Indexed: 12/21/2022]
Abstract
The implications of obesity and weight loss for human bone health are not well understood. Although the bone changes associated with weight loss are similar in humans and rodents, that is not the case for obesity. In humans, obesity is generally associated with increased bone mass, an outcome which is exacerbated by advanced age and menopause. In rodents, by contrast, bone mass decreases in proportion to severity and duration of obesity, and is influenced by sex, age and mechanical load. Despite these discrepancies, rodents are frequently used to model the situation in humans. In this review, we summarise the existing knowledge of the effects of obesity and weight loss on bone mass in humans and rodents, focusing on the translatability of findings from animal models. We then describe how animal models should be used to broaden the understanding of the relationship between obesity, weight loss, and skeletal health in humans. Specifically, we highlight the aspects of study design that should be considered to optimise translatability of the rodent models of obesity and weight loss. Notably, the sex, age, and nutritional status of the animals should ideally match those of interest in humans. With these caveats in mind, and depending on the research question asked, our review underscores that animal models can provide valuable information for obesity and weight-management research.
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Affiliation(s)
- Vivi F H Jensen
- Lund University, Department of Clinical Sciences Malmö and Skåne University Hospital, Department of Orthopedics, Inga Marie Nilssons Gata 22, 205 02 Malmö, Sweden.
| | - Anne-Marie Mølck
- Novo Nordisk A/S, Department of Safety Sciences, Imaging & Data Management, Novo Nordisk Park 1, 2760 Maaloev, Denmark
| | - Majken Dalgaard
- Novo Nordisk A/S, Department of Safety Sciences, Imaging & Data Management, Novo Nordisk Park 1, 2760 Maaloev, Denmark
| | - Fiona E McGuigan
- Lund University, Department of Clinical Sciences Malmö and Skåne University Hospital, Department of Orthopedics, Inga Marie Nilssons Gata 22, 205 02 Malmö, Sweden
| | - Kristina E Akesson
- Lund University, Department of Clinical Sciences Malmö and Skåne University Hospital, Department of Orthopedics, Inga Marie Nilssons Gata 22, 205 02 Malmö, Sweden
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Krez A, Agarwal S, Bucovsky M, McMahon DJ, Hu Y, Bessler M, Schrope B, Carrelli A, Clare S, Guo XDE, Silverberg SJ, Stein EM. Long-term Bone Loss and Deterioration of Microarchitecture After Gastric Bypass in African American and Latina Women. J Clin Endocrinol Metab 2021; 106:e1868-e1879. [PMID: 33098299 PMCID: PMC8502471 DOI: 10.1210/clinem/dgaa654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
Abstract
CONTEXT The prevalence of obesity is burgeoning among African American and Latina women; however, few studies investigating the skeletal effects of bariatric surgery have focused on these groups. OBJECTIVE To investigate long-term skeletal changes following Roux-en-Y gastric bypass (RYGB) in African American and Latina women. DESIGN Four-year prospective cohort study. PATIENTS African American and Latina women presenting for RYGB (n = 17, mean age 44, body mass index 44 kg/m2) were followed annually for 4 years postoperatively. MAIN OUTCOME MEASURES Dual-energy x-ray absorptiometry (DXA) measured areal bone mineral density (aBMD) at the spine, hip, and forearm, and body composition. High-resolution peripheral quantitative computed tomography measured volumetric bone mineral density (vBMD) and microarchitecture. Individual trabecula segmentation-based morphological analysis assessed trabecular morphology and connectivity. RESULTS Baseline DXA Z-Scores were normal. Weight decreased ~30% at Year 1, then stabilized. Parathyroid hormone (PTH) increased by 50% and 25-hydroxyvitamin D was stable. By Year 4, aBMD had declined at all sites, most substantially in the hip. There was significant, progressive loss of cortical and trabecular vBMD, deterioration of microarchitecture, and increased cortical porosity at both the radius and tibia over 4 years. There was loss of trabecular plates, loss of axially aligned trabeculae, and decreased trabecular connectivity. Whole bone stiffness and failure load declined. Risk factors for bone loss included greater weight loss, rise in PTH, and older age. CONCLUSIONS African American and Latina women had substantial and progressive bone loss, deterioration of microarchitecture, and trabecular morphology following RYGB. Further studies are critical to understand the long-term skeletal consequences of bariatric surgery in this population.
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Affiliation(s)
- Alexandra Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, New York
| | - Sanchita Agarwal
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Mariana Bucovsky
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Donald J McMahon
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, New York
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Yizhong Hu
- Bone Bioengineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York
| | - Marc Bessler
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Beth Schrope
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Angela Carrelli
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Shannon Clare
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, New York
| | - Xiang-Dong Edward Guo
- Bone Bioengineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York
| | - Shonni J Silverberg
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, New York
- Correspondence and Reprint Requests: Emily M. Stein, MD, MS, Director of Research, Metabolic Bone Service, Hospital for Special Surgery, Associate Professor of Medicine, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021. E-mail:
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9
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Huang C, Wang Q, Zhang Q, Zhou B, Lin J, Meng H. Effects of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy on Bone Mineral Density in Zucker Diabetic Fatty Rats: A Short-Term Comparative Study. Obes Facts 2021; 14:178-189. [PMID: 33662956 PMCID: PMC8138275 DOI: 10.1159/000514426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 01/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While bariatric surgery could result in weight loss as well as glycaemia improvement, the short-term impact on bone health in a high glycemic environment following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remains intriguing. OBJECTIVE The aim of this study was to compare the short-term effects of RYGB and SG procedures on bone health in Zucker diabetic fatty (ZDFfa/fa) rats. METHODS Thirty age-matched male ZDFfa/fa rats were randomized into RYGB, SG, and sham groups after establishment of the diabetic model. Body weight, blood glucose, bone mineral density (BMD), the level of bone turnover markers (BTM), vitamin D, and serum calcium and phosphorus were measured 4 weeks after the operation. RESULTS The RYGB procedure brought about lower blood glucose, BMD, serum calcium and phosphorus levels, as well as a relatively higher bone turnover rate and 1,25(OH)2VD level, compared to the SG and sham groups, while the influences of the SG procedure were not significant. 25(OH)VD demonstrated no significant difference among the 3 groups. CONCLUSIONS Despite its excellent ability to provide short-term glycemic control, the RYGB procedure could led to more severe impairment of bone health compared to the SG procedure. Bone health should be procured after bariatric surgery, especially with the RYGB procedure. Early detection of BMD and BTM may help to avoid deterioration of bone.
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Affiliation(s)
- Cheng Huang
- Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Qiong Wang
- Department of Nephrology, Beijing Hospital, Beijing, China
| | - Qin Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Biao Zhou
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jun Lin
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hua Meng
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
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Abstract
PURPOSE The prevalence of childhood obesity has increased over past decades with a concomitant increase in metabolic and bariatric surgery (MBS). While MBS in adults is associated with bone loss, only a few studies have examined the effect of MBS on the growing skeleton in adolescents. METHODS This mini-review summarizes available data on the effects of the most commonly performed MBS (sleeve gastrectomy and gastric bypass) on bone in adolescents. A literature review was performed using PubMed for English-language articles. RESULTS Dual-energy x-ray absorptiometry (DXA) measures of areal bone mineral density (aBMD) and BMD Z scores decreased following all MBS. Volumetric BMD (vBMD) by quantitative computed tomography (QCT) decreased at the lumbar spine while cortical vBMD of the distal radius and tibia increased over a year following sleeve gastrectomy (total vBMD did not change). Reductions in narrow neck and intertrochanteric cross-sectional area and cortical thickness were observed over this duration, and hip strength estimates were deleteriously impacted. Marrow adipose tissue (MAT) of the lumbar spine increased while MAT of the peripheral skeleton decreased a year following sleeve gastrectomy. The amount of weight loss and reductions in lean and fat mass correlated with bone loss at all sites, and with changes in bone microarchitecture at peripheral sites. CONCLUSION MBS in adolescents is associated with aBMD reductions, and increases in MAT of the axial skeleton, while sleeve gastrectomy is associated with an increase in cortical vBMD and decrease in MAT of the peripheral skeleton. No reductions have been reported in peripheral strength estimates.
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Affiliation(s)
- Madhusmita Misra
- Division of Pediatric Endocrinology, Mass General Hospital for Children and Harvard Medical School, Boston, Massachusetts
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Madhusmita Misra, MD, MPH, 175 Cambridge Street, 5th Floor, Boston, MA 02114, USA. E-mail:
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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11
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Mori C, Sheehan D, Graor CH, Petrinec A. A scoping review of the phenomenon of osteoporosis in post bariatric surgical patients. Int J Orthop Trauma Nurs 2020; 40:100835. [PMID: 33272902 DOI: 10.1016/j.ijotn.2020.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Risk factors, preventive treatment, and increased prevalence of fragility fractures in post-bariatric surgical patients have been researched, however, little is known about how patients' perspectives of osteoporosis risk determine their commitment to bone health. PURPOSE The purpose of this review was to provide an overview and appraisal of the research regarding osteoporosis in post bariatric surgical patients, as well as to identify gaps in the literature in this area. METHODS Data bases searched included OVID Medline, CINAHL, and EMBASE which included ahead of print articles that had not yet been indexed. Relevant key words were used independently and in combination: "osteoporosis," "morbid obesity," and "bariatric surgery." RESULTS A total of 24 quantitative studies and 15 qualitative studies were retrieved for this review; none of the qualitative studies examined both osteoporosis and bariatric surgery. CONCLUSION The current trend in bariatric surgical patients regarding osteoporosis is to examine the degree of bone loss based on significant influences including extent of weight loss, years since surgery, type of procedure performed, and subject selection. Patient perceptions about osteoporosis risk after bariatric surgery were rarely addressed.
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Affiliation(s)
- Candace Mori
- Nursing and Nursing Education, 210 Skyveiw Circle, Dalton, Ohio, USA.
| | - Denice Sheehan
- Kent State University College of Nursing, 10358 Hanford Lane, Twinsburg, OH, 44087, USA.
| | | | - Amy Petrinec
- Kent State University College of Nursing, 2760 Hawkesbury Boulevard, Hudson, OH, 44236, USA.
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12
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Ieong K, Ardila-Gatas J, Yang J, Zhang X, Tsui ST, Spaniolas K, Pryor AD. Bone mineral density changes after bariatric surgery. Surg Endosc 2020; 35:4763-4770. [PMID: 32909203 DOI: 10.1007/s00464-020-07953-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 08/27/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Although bariatric surgery is associated with multiple health benefits, decreased bone mass is a known complication of the procedure. Roux-en-Y gastric bypass (RYGB) is associated with significant bone loss and increased fracture risk. However, data on the effect of sleeve gastrectomy (SG) on bone mineral changes are sparse. The impact of vitamin D and calcium levels on bone mineral density (BMD) after SG is also unknown. METHODS A retrospective chart review was performed to include patients who underwent RYGB or SG from 2014 to 2016 at a single institution. Patients were included if bone densitometry was performed preoperatively and within 2 years postoperatively. Serum 25-hydroxy vitamin D and calcium levels were collected preoperatively and at time of bone densitometry scan. BMD and T-score changes at the femoral neck, femoral trochanter, total hip, and lumbar spine were compared between RYGB and SG patients. RESULTS A total of 40 patients were included. 24 (60%) of patients underwent RYGB and 16 (40%) patients underwent SG. No statistically significant difference in baseline characteristics was noted between RYGB and SG patients. All measurements, except for serum 25-hydroxy vitamin D, were significantly decreased in RYGB patients, postoperatively. All measurements, except for BMD and T-score at the lumbar spine and serum 25-hydroxy vitamin D, were significantly decreased in SG patients, postoperatively. The extent of decrease in serum 25-hydroxyvitamin D was significantly associated with decreased BMD (p = 0.049) and T-score (p = 0.032) at the lumbar spine. The extent of decrease in serum calcium was significantly associated with decreased BMD (p = 0.046) at the femoral neck. CONCLUSION All patients were found to have decreased BMD after RYGB and SG. Surgery type was not a significant risk factor in BMD change. Despite vitamin D and calcium supplementation in all patients, a decrease in vitamin D and calcium levels were associated with a decrease in BMD. Close follow-up and treatment of vitamin D and calcium levels are warranted in all bariatric patients.
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Affiliation(s)
- Kelly Ieong
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA.
| | - Jessica Ardila-Gatas
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Jie Yang
- Department of Family, Population and Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Xiaoyue Zhang
- Department of Family, Population and Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Stella To Tsui
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Konstantinos Spaniolas
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
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13
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Roux-en-Y gastric bypass and gastric sleeve surgery result in long term bone loss. Int J Obes (Lond) 2020; 45:235-246. [PMID: 32848203 DOI: 10.1038/s41366-020-00660-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/14/2020] [Accepted: 08/15/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Little is known about the long-term skeletal impact of bariatric procedures, particularly the increasingly commonly performed gastric sleeve surgery (GS). We examined bone density (BMD) change following three types of bariatric surgery Roux-en-Y gastric bypass (RYGB), GS and laparoscopic adjustable gastric banding (LAGB), compared with diet, over 36 months. METHODS Non-randomized, prospective study of participants with severe obesity (n = 52), undergoing weight-loss interventions: RYGB (n = 7), GS (n = 21), LAGB (n = 11) and diet (n = 13). Measurements of calciotropic indices, gut hormones (fasting and post prandial) peptide YY (PYY), glucagon-like peptide 1 (GLP1) and adiponectin together with dual-X-ray absorptiometry and quantitative computed tomography scans were performed thorough the study. RESULTS All groups lost weight during the first 12 months. Despite weight stability from 12 to 36 months and supplementation of calcium and vitamin D, there was progressive bone loss at the total hip (TH) over 36 months in RYGB -14% (95% CI: -12, -17) and GS -9% (95% CI: -7, -10). In RYGB forearm BMD also declined over 36 months -9% (95% CI: -6, -12) and LS BMD declined over the first 12 months -7% (95% CI: -3, -12). RYGB and GS groups experienced significantly greater bone loss until 36 months than LAGB and diet groups, which experienced no significant BMD loss. These bone losses remained significant after adjustment for weight loss and age. RYGB and GS procedures resulted in elevated postprandial PYY, adiponectin and bone turnover markers up to 36 months without such changes among LAGB and diet participants. CONCLUSIONS RYGB and GS but not LAGB resulted in ongoing TH bone loss for three postoperative years. For RYGB, bone loss was also observed at LS and non-weight-bearing forearms. These BMD changes were independent of weight and age differences. We, therefore, recommend close monitoring of bone health following RYGB and GS surgeries.
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14
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Effects of gastric sleeve surgery on the serum levels of GH, IGF-1 and IGF-binding protein 2 in healthy obese patients. BMC Gastroenterol 2020; 20:199. [PMID: 32586279 PMCID: PMC7318424 DOI: 10.1186/s12876-020-01309-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/19/2020] [Indexed: 12/21/2022] Open
Abstract
Background Bariatric surgery is an effective treatment for severe obesity. It also ameliorates diabetes independently of weight loss through mechanisms that are not fully understood. In this study, we investigated the levels of GH, IGF-1 and IGF-binding protein 2 (IGFBP-2) after gastric sleeve surgery in healthy obese individuals. Method This study was conducted in 33 obese (BMI > 38.3) healthy male subjects aged 25 to 50 years undergoing sleeve gastrectomy. GH, IGF-1 and IGFBP-2 levels were evaluated by ELISA at baseline and 6–12 months after surgery. Other parameters, such as glucose, BMI, insulin, HOMA-IR and lipid profile, were also investigated. Results Systemic GH (12.32 vs. 50.97 pg/mL, p < 0.001) and IGFBP-2 levels (51.86 vs. 68.81 pg/mL, p < 0.001) were elevated after bariatric surgery. There was no change in IGF-1 level from before to after surgery. BMI (52.18 vs. 40.11, p = 0.001), insulin (19.35 vs. 8.80 mIU/L, p < 0.001) and HOMA-IR index (6.48 to 2.52, p < 0.001) were reduced after surgery. Lipid profile analysis revealed that total cholesterol (4.26 vs. 5.12 mmol/L, p < 0.001) and high-density lipoprotein (HDL) (0.90 to 1.55 mmol/L, p < 0.001) were increased, while triglycerides were decreased, after surgery (1.62 vs. 1.05 mmol/L p < 0.001). GH, IGF-1, and IGFBP-2 were not correlated with insulin or lipid parameters. Conclusions Our study suggests that improved circulating GH and IGFBP-2 levels may mediate the beneficial effects of gastric sleeve surgery in improving insulin sensitivity and reducing insulin demand.
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Guerrero-Pérez F, Casajoana A, Gómez-Vaquero C, Virgili N, López-Urdiales R, Hernández-Montoliu L, Pujol-Gebelli J, Osorio J, Prats A, Vidal-Alabró A, Pérez-Maraver M, Fernández-Veledo S, Vendrell J, Vilarrasa N. Long-Term Effects in Bone Mineral Density after Different Bariatric Procedures in Patients with Type 2 Diabetes: Outcomes of a Randomized Clinical Trial. J Clin Med 2020; 9:jcm9061830. [PMID: 32545353 PMCID: PMC7356739 DOI: 10.3390/jcm9061830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/16/2022] Open
Abstract
There is scant evidence of the long-term effects of bariatric surgery on bone mineral density (BMD). We compared BMD changes in patients with severe obesity and type 2 diabetes (T2D) 5 years after randomization to metabolic gastric bypass (mRYGB), sleeve gastrectomy (SG) and greater curvature plication (GCP). We studied the influence of first year gastrointestinal hormone changes on final bone outcomes. Forty-five patients, averaging 49.4 (7.8) years old and body mass index (BMI) 39.4 (1.9) kg/m2, were included. BMD at lumbar spine (LS) was lower after mRYGB compared to SG and GCP: 0.89 [0.82;0.94] vs. 1.04 [0.91;1.16] vs. 0.99 [0.89;1.12], p = 0.020. A higher percentage of LS osteopenia was present after mRYGB 78.6% vs. 33.3% vs. 50.0%, respectively. BMD reduction was greater in T2D remitters vs. non-remitters. Weight at fifth year predicted BMD changes at the femoral neck (FN) (adjusted R2: 0.3218; p = 0.002), and type of surgery (mRYGB) and menopause predicted BMD changes at LS (adjusted R2: 0.2507; p < 0.015). In conclusion, mRYGB produces higher deleterious effects on bone at LS compared to SG and GCP in the long-term. Women in menopause undergoing mRYGB are at highest risk of bone deterioration. Gastrointestinal hormone changes after surgery do not play a major role in BMD outcomes.
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Affiliation(s)
- Fernando Guerrero-Pérez
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (N.V.); (R.L.-U.); (L.H.-M.); (M.P.-M.)
| | - Anna Casajoana
- Bariatric Surgery Unit, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.C.); (J.P.-G.); (J.O.)
| | - Carmen Gómez-Vaquero
- Department of Rheumatology, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain;
| | - Nuria Virgili
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (N.V.); (R.L.-U.); (L.H.-M.); (M.P.-M.)
| | - Rafael López-Urdiales
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (N.V.); (R.L.-U.); (L.H.-M.); (M.P.-M.)
| | - Laura Hernández-Montoliu
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (N.V.); (R.L.-U.); (L.H.-M.); (M.P.-M.)
| | - Jordi Pujol-Gebelli
- Bariatric Surgery Unit, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.C.); (J.P.-G.); (J.O.)
| | - Javier Osorio
- Bariatric Surgery Unit, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.C.); (J.P.-G.); (J.O.)
| | - Anna Prats
- Clinical Nutrition Unit, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain;
| | - Anna Vidal-Alabró
- Instituto de Investigación Biomédica-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain;
| | - Manuel Pérez-Maraver
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (N.V.); (R.L.-U.); (L.H.-M.); (M.P.-M.)
- Instituto de Investigación Biomédica-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain;
- CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 28014 Madrid, Spain; (S.F.-V.); (J.V.)
| | - Sonia Fernández-Veledo
- CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 28014 Madrid, Spain; (S.F.-V.); (J.V.)
- Pere Virgili Research Institute (IISPV), University Hospital Joan XXIII, 43005and Rovira i Virgili University, 43003 Tarragona, Spain
| | - Joan Vendrell
- CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 28014 Madrid, Spain; (S.F.-V.); (J.V.)
- Pere Virgili Research Institute (IISPV), University Hospital Joan XXIII, 43005and Rovira i Virgili University, 43003 Tarragona, Spain
| | - Nuria Vilarrasa
- Department of Endocrinology and Nutrition, Bellvitge University Hospital-IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (N.V.); (R.L.-U.); (L.H.-M.); (M.P.-M.)
- CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, 28014 Madrid, Spain; (S.F.-V.); (J.V.)
- Correspondence: ; Tel.: +34-932-602-784
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Abstract
PURPOSE OF REVIEW This review outlines the recent findings regarding the impact of bariatric surgery on bone. It explores potential mechanisms for skeletal changes following bariatric surgery and strategies for management. RECENT FINDINGS Bone loss following bariatric surgery is multifactorial. Probable mechanisms include skeletal unloading, abnormalities in calciotropic hormones, and changes in gut hormones. Skeletal changes that occur after bariatric surgery are specific to procedure type and persist for several years post-operatively. Studies suggest that while bone loss begins early, fracture risk may be increased later in the post-operative course, particularly after Roux-en-Y gastric bypass (RYGB). Further research is needed to assess the extent to which skeletal changes following bariatric surgery result in fragility. Current management should be geared toward prevention of bone loss, correction of nutritional deficiencies, and incorporation of weight bearing exercise. Pharmacologic treatment should be considered for high-risk patients.
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Affiliation(s)
- Alexandra N Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery New York, New York, USA
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery New York, New York, USA.
- Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA.
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Saad R, Habli D, El Sabbagh R, Chakhtoura M. Bone Health Following Bariatric Surgery: An Update. J Clin Densitom 2020; 23:165-181. [PMID: 31519474 DOI: 10.1016/j.jocd.2019.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/02/2019] [Accepted: 08/05/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Randa Saad
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine-American University of Beirut Medical Center, Beirut, Lebanon
| | - Dalal Habli
- Department of Internal Medicine - American University of Beirut Medical Center, Beirut, Lebanon
| | - Rawaa El Sabbagh
- Department of Internal Medicine - American University of Beirut Medical Center, Beirut, Lebanon
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine-American University of Beirut Medical Center, Beirut, Lebanon.
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18
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Luhrs AR, Davalos G, Lerebours R, Yoo J, Park C, Tabone L, Omotosho P, Torquati A, Portenier D, Guerron AD. Determining changes in bone metabolism after bariatric surgery in postmenopausal women. Surg Endosc 2020; 34:1754-1760. [PMID: 31209602 PMCID: PMC7373333 DOI: 10.1007/s00464-019-06922-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accelerated bone loss is a known complication after bariatric surgery. Bone mineral density has been shown to decrease significantly after Laparoscopic Roux-en-Y gastric bypass (RYGB). Laparoscopic sleeve gastrectomy (SG) effects on bone density are largely unknown. This should be considered for those with increased preoperative risk for bone loss, such as postmenopausal females. METHODS This prospective clinical trial included postmenopausal patients, with BMI ≥ 35 k/m2, being evaluated for either RYGB or SG. Patients with history of osteoporosis, estrogen hormone replacement therapy, active smoking, glucocorticoid use, or weight > 295 lb were excluded. Patients underwent DEXA scans preoperatively and 1 year postoperatively with measurement of total body bone mineral density (BMD) and bone mineral content (BMC) as well as regional site-specific BMD and BMC. RESULTS A total of 28 patients were enrolled. 16 (57.1%) patients underwent RYGB and 12 (42.9%) patients underwent SG. Median preoperative BMI was 44.2 k/m2 (IQR 39.9, 46.6). Median change in BMI at 12 months was - 11.3 k/m2 (IQR - 12.8, - 7.9). A significant reduction in total body BMC was seen when comparing preoperative measurements to postoperative measurements (2358.32 vs 2280.68 grams; p = 0.002). Regional site BMC and BMD significantly decreased in the ribs and spine postoperatively (p = < 0.02) representing the greatest loss in the axial skeleton. Comparing those who underwent RYGB to SG there was no significant difference between the two groups when evaluating changes in total or regional site BMD. CONCLUSION Postmenopausal women were found to have decreased BMD and BMC after RYGB and SG, suggesting that high-risk women may benefit from postoperative DEXA screening. Further study is needed to determine the clinical significance of these findings. It is unknown if these changes in BMD are due to modifiable factors (Vitamin D level, activity level, hormone status, etc.), and whether BMD and BMC is recovered beyond 1 year.
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Affiliation(s)
- Andrew R Luhrs
- Department of Surgery, Duke University Medical Center, 407 Crutchfield St, Durham, NC, 27704, USA
| | - Gerardo Davalos
- Department of Surgery, Duke University Medical Center, 407 Crutchfield St, Durham, NC, 27704, USA
| | - Reginald Lerebours
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jin Yoo
- Department of Surgery, Duke University Medical Center, 407 Crutchfield St, Durham, NC, 27704, USA
| | - Chan Park
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | - Lawrence Tabone
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | | | | | - Dana Portenier
- Department of Surgery, Duke University Medical Center, 407 Crutchfield St, Durham, NC, 27704, USA
| | - Alfredo D Guerron
- Department of Surgery, Duke University Medical Center, 407 Crutchfield St, Durham, NC, 27704, USA.
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Jalali SM, Azadbakht M, Azadbakht S, Daniali S, Farokhi E. Prevalence of secondary hyperparathyroidism following bariatric surgery. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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20
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Luger M, Kruschitz R, Winzer E, Schindler K, Grabovac I, Kainberger F, Krebs M, Hoppichler F, Langer F, Prager G, Marculescu R, Ludvik B. Changes in Bone Mineral Density Following Weight Loss Induced by One-Anastomosis Gastric Bypass in Patients with Vitamin D Supplementation. Obes Surg 2019; 28:3454-3465. [PMID: 29968187 DOI: 10.1007/s11695-018-3353-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about changes in bone mineral density (BMD) following weight loss after one-anastomosis gastric bypass (OAGB) and the role of serum vitamin D and its supplementation on bone metabolism. We evaluated BMD after OAGB as a function of vitamin D supplementation with respect to a minimum threshold of 25-hydroxy-vitamin-D [25(OH)D] concentration, which could prevent or decelerate an eventual bone loss. METHODS Fifty bariatric patients who participated in the randomized controlled trial were included in this analysis. BMD and anthropometric measurements by DXA and laboratory parameters were assessed before (T0), at 6 (T6), and 12 months (T12) after surgery. RESULTS OAGB resulted in a 36% total body weight loss with a decrease in body fat and an increase in lean body mass. A significant decrease in BMD was seen in lumbar spine by 7%, left hip 13%, and total body 1%, but not in forearm. Bone turnover markers increased significantly but with normal parathyroid hormone concentrations. Weight loss was not associated with changes in BMD. A serum 25(OH)D concentration > 50 nmol/l at T6 and T12 (adequate-vitamin-D-group; AVD) showed a significant lower bone loss, compared to the inadequate-vitamin-D-group (IVD; < 50 nmol/l). Lower bone loss in the left hip showed a strong correlation with higher 25(OH)D concentrations (r = 0.635, p = 0.003). CONCLUSION These findings support a dose effect of vitamin D supplementation on bone health and suggest that 25(OH)D concentrations need to be above 50 nmol/l at least during the first postoperative year to decelerate bone loss in patients undergoing OAGB. CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE Clinicaltrials.gov (NCT02092376) at https://clinicaltrials.gov /. EudraCT (2013-003546-16) at https://eudract.ema.europa.eu /.
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Affiliation(s)
- Maria Luger
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Special Institute for Preventive Cardiology And Nutrition-SIPCAN, Rabenfleckweg 8, Elsbethen, 5061, Salzburg, Austria.,Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria
| | - Renate Kruschitz
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Division of Internal Medicine, General public hospital of the Order of Saint Elisabeth, Völkermarkter Straße 15-19, 9020, Klagenfurt, Austria
| | - Eva Winzer
- Special Institute for Preventive Cardiology And Nutrition-SIPCAN, Rabenfleckweg 8, Elsbethen, 5061, Salzburg, Austria. .,Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria.
| | - Karin Schindler
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria
| | - Franz Kainberger
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Michael Krebs
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Friedrich Hoppichler
- Special Institute for Preventive Cardiology And Nutrition-SIPCAN, Rabenfleckweg 8, Elsbethen, 5061, Salzburg, Austria.,Division of Internal Medicine, Krankenhaus der Barmherzigen Brüde Salzburgr, Kajetanerplatz 1, 5010, Salzburg, Austria
| | - Felix Langer
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gerhard Prager
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Rodrig Marculescu
- Clinical Institute for Medical and Chemical Laboratory Diagnostics, Department of Laboratory Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Bernhard Ludvik
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Medicine 1 and Karl Landsteiner Institute for Obesity and Metabolic Diseases, Rudolfstiftung Hospital, Juchgasse 25, 1030, Vienna, Austria
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21
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Cornejo-Pareja I, Clemente-Postigo M, Tinahones FJ. Metabolic and Endocrine Consequences of Bariatric Surgery. Front Endocrinol (Lausanne) 2019; 10:626. [PMID: 31608009 PMCID: PMC6761298 DOI: 10.3389/fendo.2019.00626] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 08/29/2019] [Indexed: 12/17/2022] Open
Abstract
Obesity is one of the most serious worldwide epidemics of the twenty-first century according to the World Health Organization. Frequently associated with a number of comorbidities, obesity threatens and compromises individual health and quality of life. Bariatric surgery (BS) has been demonstrated to be an effective treatment to achieve not only sustained weight loss but also significant metabolic improvement that goes beyond mere weight loss. The beneficial effects of BS on metabolic traits are so widely recognized that some authors have proposed BS as metabolic surgery that could be prescribed even for moderate obesity. However, most of the BS procedures imply malabsorption and/or gastric acid reduction which lead to nutrient deficiency and, consequently, further complications could be developed in the long term. In fact, BS not only affects metabolic homeostasis but also has pronounced effects on endocrine systems other than those exclusively involved in metabolic function. The somatotropic, corticotropic, and gonadal axes as well as bone health have also been shown to be affected by the various BS procedures. Accordingly, further consequences and complications of BS in the long term in systems other than metabolic system need to be addressed in large cohorts, taking into account each bariatric procedure before making generalized recommendations for BS. In this review, current data regarding these issues are summarized, paying special attention to the somatotropic, corticotropic, gonadal axes, and bone post-operative health.
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Affiliation(s)
- Isabel Cornejo-Pareja
- Unidad de Gestión Clínica Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga—IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Málaga, Spain
| | - Mercedes Clemente-Postigo
- Unidad de Gestión Clínica Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga—IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Málaga, Spain
- *Correspondence: Mercedes Clemente-Postigo
| | - Francisco J. Tinahones
- Unidad de Gestión Clínica Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga—IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Málaga, Spain
- Francisco J. Tinahones
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22
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Abstract
The interaction between obesity and bone metabolism is complex. The effects of fat on the skeleton are mediated by both mechanical and biochemical factors. Though obesity is characterized by higher bone mineral density, studies conducted on bone microarchitecture have produced conflicting results. The majority of studies indicate that obesity has a positive effect on skeletal strength, even though most likely the effects are site-dependent and, in fact, obese individuals might be at risk of certain types of fractures. Mechanical loading and higher lean mass are associated with improved outcomes, whereas systemic inflammation, observed especially with abdominal obesity, may exert negative effects. Weight loss interventions likely lead to bone loss over time. Pharmacological treatment options seem to be safe in terms of skeletal health; however, the skeletal effects of bariatric surgery are dependent on the type of surgical procedure. Malabsorptive procedures are associated with higher short-term adverse effects on bone health. In this narrative review, we discuss the effects of obesity and weight loss interventions on skeletal health.
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Affiliation(s)
- Christos Savvidis
- Department of Endocrinology, Hippokrateion General Hospital, Athens, Greece
| | - Symeon Tournis
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", KAT hospital, Medical school, Athens, Greece
| | - Anastasia D Dede
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", KAT hospital, Medical school, Athens, Greece.
- Department of Endocrinology and Diabetes, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.
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23
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Gagnon C, Schafer AL. Bone Health After Bariatric Surgery. JBMR Plus 2018; 2:121-133. [PMID: 30283897 PMCID: PMC6124196 DOI: 10.1002/jbm4.10048] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 03/13/2018] [Accepted: 03/26/2018] [Indexed: 02/06/2023] Open
Abstract
Bariatric surgery results in long-term weight loss and improvement or resolution in obesity-related comorbidities. However, mounting evidence indicates that it adversely affects bone health. This review summarizes clinical research findings about the impact of bariatric surgery on skeletal outcomes. The literature is the largest and strongest for the Roux-en-Y gastric bypass (RYGB) procedure, as RYGB was the most commonly performed bariatric procedure worldwide until it was very recently overtaken by the sleeve gastrectomy (SG). Because SG is a newer procedure, its skeletal effects have not yet been well defined. Epidemiologic studies have now demonstrated an increased risk of fracture after RYGB and biliopancreatic diversion with duodenal switch, both of which include a malabsorptive component. As these epidemiologic data have emerged, patient-oriented studies have elucidated the bone tissue-level changes that may account for the heightened skeletal fragility. Bariatric surgery induces early and dramatic increases in biochemical markers of bone turnover. A notable feature of recent patient-oriented clinical studies is the application of advanced skeletal imaging modalities; studies address the limitations of dual-energy X-ray absorptiometry (DXA) by using quantitative computed tomography (QCT)-based modalities to examine volumetric bone mineral density and compartment-specific density and microstructure. RYGB results in pronounced declines in bone mass at the axial skeleton demonstrated by DXA and QCT, as well as at the appendicular skeleton demonstrated by high-resolution peripheral quantitative computed tomography (HR-pQCT). RYGB has detrimental effects on trabecular and cortical microarchitecture and estimated bone strength. Skeletal changes after RYGB appear early and continue even after weight loss plateaus and weight stabilizes. The skeletal effects of bariatric surgery are presumably multifactorial, and mechanisms may involve nutritional factors, mechanical unloading, hormonal factors, and changes in body composition and bone marrow fat. Clinical guidelines address bone health and may mitigate the negative skeletal effects of surgery, although more research is needed to direct and support such guidelines. © 2018 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Claudia Gagnon
- Department of MedicineUniversité LavalQuebec CityCanada
- Endocrinology and Nephrology UnitCHU de Quebec Research CentreQuebec CityCanada
- Institute of Nutrition and Functional FoodsUniversité LavalQuebec CityCanada
- Quebec Heart and Lung Institute Research CentreQuébec CityCanada
| | - Anne L Schafer
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCAUSA
- Endocrine Research UnitSan Francisco Veterans Affairs Heath Care SystemSan FranciscoCAUSA
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24
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Zhang Q, Chen Y, Li J, Chen D, Cheng Z, Xu S, Huang Y, Wang Q. A meta-analysis of the effects of bariatric surgery on fracture risk. Obes Rev 2018; 19:728-736. [PMID: 29334691 DOI: 10.1111/obr.12665] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 02/05/2023]
Abstract
Bariatric surgery effectively treats morbid obesity. However, the negative effect of this surgery on the bone is concerning. The aim of this meta-analysis was to investigate the fracture risk associated with bariatric surgery in morbidly obese subjects. Relevant studies published from database inception to September 2017 were identified in PubMed, Embase and the Cochrane Library. The Newcastle-Ottawa Scale was used to evaluate the quality of the observational studies, and the Jadad score evaluated randomized controlled trials. Among the 1003 studies initially identified, five observational trials and one randomized controlled trial were eligible for inclusion. All studies included in the meta-analysis were considered high quality. Risk for any type of fracture was higher in the surgical group than in the non-surgical group (risk ratio [RR] 1.29, 95% confidence interval [CI] 1.18-1.42). After surgery, the fracture risk in non-vertebral sites was significantly increased, especially in the upper limbs (RR 1.42, 95% CI 1.08-1.87; and RR 1.68, 95% CI 1.15-2.45). Compared with those with restrictive procedures, subjects who underwent mixed restrictive and malabsorptive procedures tended to have an increased fracture risk (RR 1.54, 95% CI 0.96-2.46). To conclude, bariatric surgery is associated with an increased risk of total and non-vertebral fractures, especially in the upper limbs.
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Affiliation(s)
- Q Zhang
- Department of Endocrinology and Metabolism, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Y Chen
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - J Li
- Department of Endocrinology and Metabolism, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - D Chen
- Department of Endocrinology and Metabolism, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Z Cheng
- Department of Gastrointestinal Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - S Xu
- Department of Endocrinology and Metabolism, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Y Huang
- Department of Endocrinology and Metabolism, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Q Wang
- Department of Endocrinology and Metabolism, Sichuan University West China Hospital, Chengdu, Sichuan, China
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Ben-Porat T, Elazary R, Sherf-Dagan S, Goldenshluger A, Brodie R, Mintz Y, Weiss R. Bone Health following Bariatric Surgery: Implications for Management Strategies to Attenuate Bone Loss. Adv Nutr 2018; 9:114-127. [PMID: 29659692 PMCID: PMC5916426 DOI: 10.1093/advances/nmx024] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/11/2017] [Accepted: 12/18/2017] [Indexed: 01/19/2023] Open
Abstract
Bariatric surgery (BS) is an effective treatment for morbid obesity and its associated comorbidities. Following such a procedure, however, patients are at risk of developing metabolic bone disease owing to the combination of rapid weight loss, severely restricted dietary intake, and reduced intestinal nutrient absorption. Patients undergoing malabsorptive procedures are at a higher risk of postoperative bone health deterioration than those undergoing restrictive procedures; however, studies have demonstrated negative skeletal consequences of restrictive procedures as well. The clinical practice guidelines of some international associations have previously addressed preoperative evaluation and postoperative clinical care in order to maintain bone health in BS patients. Nevertheless, some issues regarding bone health in BS patients remain unclear owing to the lack of relevant randomized clinical trials, including doses of nutritional supplements pre- and post-BS. This review summarizes the current data regarding the skeletal consequences of BS and its mechanisms, with an emphasis on the preventive strategies and nutritional care that may be warranted in order to attenuate bone deterioration following BS.
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Affiliation(s)
- Tair Ben-Porat
- Departments of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Human Metabolism and Nutrition, Hebrew University, Jerusalem, Israel
| | - Ram Elazary
- Departments of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Ariela Goldenshluger
- Departments of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Brodie
- Departments of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Mintz
- Departments of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Weiss
- Department of Human Metabolism and Nutrition, Hebrew University, Jerusalem, Israel
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26
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Brynskov T, Laugesen CS, Svenningsen AL, Floyd AK, Sørensen TL. Monitoring of Diabetic Retinopathy in relation to Bariatric Surgery: a Prospective Observational Study. Obes Surg 2018; 26:1279-86. [PMID: 26476835 DOI: 10.1007/s11695-015-1936-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND To investigate the need for closer perioperative monitoring of diabetic retinopathy in patients with type 2 diabetes undergoing bariatric surgery. METHODS Prospective observational clinical study of 56 patients with type 2 diabetes undergoing bariatric surgery. The patients were examined with 7-field fundus images and optical coherence tomography scans 2 weeks before and 1, 3, 6 and 12 months after bariatric surgery. Worsening was defined as a two-step change in the Wisconsin Epidemiologic Study of Diabetic Retinopathy scale or appearance or worsening of macular edema. Postoperative changes were analyzed in a mixed model. RESULTS Six patients (11 %) had any worsening at any visit, and three (5 %) persisted at 1 year. Of the 24 patients with preoperative retinopathy, 4-13 % worsened and 9-22 % improved, with significant overall improvement at 6 months (p = 0.01). Only one (3%) of the 32 patients without preoperative diabetic retinopathy had a transient worsening at 6 months. No patients developed macular edema, but the whole cohort had a minor increase in center point foveal thickness that peaked 6 months postoperatively. The patients were required to have good glucose control preoperatively where HbA1c was 6.4 ± 1.9 %. CONCLUSIONS Diabetic retinopathy was clinically stable after bariatric surgery, and none of the observed changes would have resulted in a changed screening interval at our center. This supports adherence to regular diabetic retinopathy screening guidelines following bariatric surgery in well-controlled patients. A clinically negligible but statistically significant foveal thickening 6 months postoperatively warrants further study.
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Affiliation(s)
- Troels Brynskov
- Department of Ophthalmology, Copenhagen University Hospital Roskilde, Køgevej 7-13, 4000, Roskilde, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Caroline Schmidt Laugesen
- Department of Ophthalmology, Copenhagen University Hospital Roskilde, Køgevej 7-13, 4000, Roskilde, Denmark
| | | | - Andrea Karen Floyd
- Department of Bariatric Surgery, Copenhagen University Hospital Køge, Køge, Denmark
| | - Torben Lykke Sørensen
- Department of Ophthalmology, Copenhagen University Hospital Roskilde, Køgevej 7-13, 4000, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Is Trabecular Bone Score Valuable in Bone Microstructure Assessment after Gastric Bypass in Women with Morbid Obesity? Nutrients 2017; 9:nu9121314. [PMID: 29207490 PMCID: PMC5748764 DOI: 10.3390/nu9121314] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/22/2017] [Accepted: 11/28/2017] [Indexed: 12/18/2022] Open
Abstract
Introduction: The effects of bariatric surgery on skeletal health raise many concerns. Trabecular bone score (TBS) is obtained through the analysis of lumbar spine dual X-ray absorptiometry (DXA) images and allows an indirect assessment of skeletal microarchitecture (MA). The aim of our study was to evaluate the changes in bone mineral density (BMD) and alterations in bone microarchitecture assessed by TBS in morbidly obese women undergoing Roux-en-Y gastric bypass (RYGB), over a three-year follow-up. Material/Methods: A prospective study of 38 morbidly obese white women, aged 46.3 ± 8.2 years, undergoing RYGB was conducted. Biochemical analyses and DXA scans with TBS evaluation were performed before and at one year and three years after surgery. Results: Patients showed normal calcium and phosphorus plasma concentrations throughout the study. However, 25-hydroxyvitamin D (25(OH)D3) decreased, and 71% of patients had a vitamin D deficiency at three years. BMD at femoral neck and lumbar spine (LSBMD) significantly decreased 13.53 ± 5.42% and 6.03 ± 6.79%, respectively, during the three-year follow-up; however Z-score values remained above those for women of the same age. TBS was within normal ranges at one and three years (1.431 ± 106 and 1.413 ± 85, respectively), and at the end of the study, 73.7% of patients had normal bone MA. TBS at three years correlated inversely with age (r = −0.41, p = 0.010), body fat (r = −0.465, p = 0.004) and greater body fat deposited in trunk (r = −0.48, p = 0.004), and positively with LSBMD (r = 0.433, p = 0.007), fat mass loss (r = 0.438, p = 0.007) and lean mass loss (r = 0.432, p = 0.008). In the regression analysis, TBS remained associated with body fat (β = −0.625, p = 0.031; R2 = 0.47). The fracture risk, calculated by FRAX® (University of Sheffield, Sheffield, UK), with and without adjustment by TBS, was low. Conclusion: Women undergoing RYGB in the mid-term have a preserved bone MA, assessed by TBS.
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28
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Brynskov T, Laugesen CS, Floyd AK, Frystyk J, Sørensen TL. The IGF-Axis and Diabetic Retinopathy Before and After Gastric Bypass Surgery. Obes Surg 2017; 27:408-415. [PMID: 27465937 DOI: 10.1007/s11695-016-2303-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Laparoscopic gastric bypass (LGB) abruptly causes remission of type 2 diabetes (T2D). Such dramatic metabolic changes have previously been found to cause worsening of diabetic retinopathy (DR) and circulating insulin-like growth factor I (IGF-I) has been suggested as a causal mediator. We aimed to evaluate baseline imbalances in the circulating IGF-system and changes after LGB in patients with T2D. METHODS Prospective ocular examinations and measurement of the IGF-axis before and 3 and 12 months after LGB. IGF-bioactivity was measured by cell-based IGF-I receptor (IGF-IR) kinase activation assay (bioactive IGF). Total IGF-I, IGF-II and IGF binding protein (IGFBP) 1 and 3 were determined by immunoassays. RESULTS At baseline, 18 of 36 patients presented with DR. These patients had higher levels of bioactive IGF (p = 0.03) than patients without DR and this association was strengthened in multivariate analysis (p = 0.006). Three patients had worsening of DR, unrelated to other markers. In univariate analysis, bioactive IGF increased at 3 months (p = 0.05) but this change became insignificant in multivariate analysis (p = 0.11). IGFBP-1 increased whereas IGFBP-3 and total IGF-II decreased at the two postoperative visits (p ≤ 0.001). Total IGF-I showed no significant changes. HbA1c, glucose, HOMA-IR and lipids improved after surgery. Two patients did not complete the 12-month visit. CONCLUSIONS In obese T2D patients, bioactive IGF is a potential biomarker for DR and levels tended to increase 3 months after bariatric surgery. IGFBP-1 increased while IGFBP-3 and total IGF-II decreased postoperatively, but these changes were unassociated with the development of DR. Markers of the metabolic syndrome improved.
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Affiliation(s)
- Troels Brynskov
- Department of Ophthalmology, Zealand University Hospital Roskilde, Roskilde, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Andrea Karen Floyd
- Department of Bariatric Surgery, Zealand University Hospital Køge, Køge, Denmark
| | - Jan Frystyk
- Medical Research Laboratory, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Lykke Sørensen
- Department of Ophthalmology, Zealand University Hospital Roskilde, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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29
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Hayashi A, Maeda Y, Takemoto M, Tokuyama H, Koide H, Kitahara A, Hayashi H, Kitamoto T, Yamaga M, Kobayashi K, Yokote K. Outcomes of laparoscopic sleeve gastrectomy in elderly obese Japanese patients. Geriatr Gerontol Int 2017; 17:2068-2073. [PMID: 28371292 DOI: 10.1111/ggi.13022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/29/2016] [Accepted: 01/17/2017] [Indexed: 12/28/2022]
Abstract
AIM Laparoscopic sleeve gastrectomy (LSG) has proven to be the most effective strategy for the treatment of morbid obesity, however its efficacy and safety in an aging population has not yet been confirmed. In this study, we evaluated the effectiveness and safety of LSG in elderly obese Japanese patients. METHODS Three obese individuals aged >60 years and 11 obese individuals aged <60 years who underwent LSG were enrolled. Pre- and postoperative changes after at least 12 months were examined, including bodyweight, body mass index, total weight loss, excess weight loss, bone mineral density and bone-related markers. RESULTS There were no significant differences between patients aged <60 years and >60 years in terms of percent total weight loss (24.4 ± 11 vs 23 ± 4.4%, respectively) and percent excess weight loss (49.1 ± 23.4 vs 47.6 ± 10 %, respectively). Dual-energy X-ray absorptiometry was carried out before and 12 months after LSG. There were no significant differences in bone mineral density changes at the lumbar spine and femoral neck between the two groups (0.01 ± 0.06 vs 0.02 ± 0.03 g/cm2 , -0.03 ± 0.06 vs -0.08 ± 0.02 g/cm2 , respectively). There were no peri- and postoperative complications. All three patients aged >60 years had reduced bone mineral density in the femoral neck after LSG; one was diagnosed with osteoporosis. CONCLUSIONS Although the present results suggest that LSG could be of considerable benefit to elderly obese Japanese patients, long-term careful observation after bariatric surgery is especially important in elderly patients to prevent future osteoporosis. Geriatr Gerontol Int 2017; 17: 2068-2073.
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Affiliation(s)
- Aiko Hayashi
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Yukari Maeda
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Minoru Takemoto
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Hirotake Tokuyama
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Yu-karigaoka Tokuyama Clinic, Chiba, Japan
| | - Hisashi Koide
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Aya Kitahara
- Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Hideki Hayashi
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takumi Kitamoto
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Masaya Yamaga
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Kazuki Kobayashi
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Kokuho Asahi-chuo hospital, Chiba, Japan
| | - Koutaro Yokote
- Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Medicine, Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
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Abstract
BACKGROUND The aim is to evaluate via meta-analysis bone metabolism and bone mineral density (BMD) in morbidly obese patients before and after bariatric surgery. METHODS We searched Medline, EMBASE, and the Cochrane Library for relevant studies published before January 2014. The following outcomes were evaluated: serum calcium, serum parathyroid hormone (PTH), serum 25-hydroxyvitamin D [25(OH)D], serum or urinary N-telopeptide (NTX), bone-specific alkaline phosphatase (BSAP), and bone mineral density (BMD). RESULTS Ten studies, including 344 patients, met our inclusion criteria. Results showed a significant decrease in serum calcium (MD = -0.10, 95 %CI -0.14 to -0.07, P < 0.00001) and increase in serum PTH (MD = 12.41, 95 %CI 6.51 to 18.31, P < 0.00001) but no significant difference in serum 25(OH)D (MD = 1.35, 95 %CI -1.12 to 3.83, P = 0.28) following bariatric surgery. There were significant increases in serum or urinary NTX (MD = 18.49, 95 %CI 3.33 to 33.66, P = 0.02) and BSAP (MD = 7.47, 95 %CI 0.21 to 14.72, P = 0.04) but a significant decrease in BMD (MD = -0.08, 95 %CI -0.13 to -0.04, P < 0.00001) after bariatric surgery. CONCLUSION BMD was significantly decreased, while bone turnover was elevated, and bone remodeling was accelerated following bariatric surgery. Basal bone metabolism should be evaluated preoperatively. To prevent secondary hyperparathyroidism and bone loss, calcium and vitamin D should be monitored closely and supplemented accordingly after the surgery.
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Chakhtoura MT, Nakhoul NN, Shawwa K, Mantzoros C, El Hajj Fuleihan GA. Hypovitaminosis D in bariatric surgery: A systematic review of observational studies. Metabolism 2016; 65:574-85. [PMID: 26805016 PMCID: PMC4792683 DOI: 10.1016/j.metabol.2015.12.004] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 11/08/2015] [Accepted: 12/12/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Obesity is a public health problem that carries global and substantial social and economic burden. Relative to non-surgical interventions, bariatric surgery has the most substantial and lasting impact on weight loss. However, it leads to a number of nutritional deficiencies requiring long term supplementation. OBJECTIVES The aims of this paper are to review 25-hydroxyvitamin D [25(OH)D] status pre and post bariatric surgery, describe the dose response of vitamin D supplementation, and assess the effect of the surgical procedure on 25(OH)D level following supplementation. METHODS We searched Medline, PubMed, the Cochrane Library and EMBASE, for relevant observational studies published in English, from 2000 to April 2015. The identified references were reviewed, in duplicate and independently, by two reviewers. RESULTS We identified 51 eligible observational studies assessing 25(OH)D status pre and/or post bariatric surgery. Mean pre-surgery 25(OH)D level was below 30ng/ml in 29 studies, and 17 of these studies showed mean 25(OH)D levels ≤20ng/ml. Mean 25(OH)D levels remained below 30ng/ml following bariatric surgery, despite various vitamin D replacement regimens, with only few exceptions. The increase in post-operative 25(OH)D levels tended to parallel increments in vitamin D supplementation dose but varied widely across studies. An increase in 25(OH)D level by 9-13ng/ml was achieved when vitamin D deficiency was corrected using vitamin D replacement doses of 1100-7100IU/day, in addition to the usual maintenance equivalent daily dose of 400-2000IU (total equivalent daily dose 1500-9100IU). There was no difference in mean 25(OH)D level following supplementation between malabsorptive/combination procedures and restrictive procedures. CONCLUSION Hypovitaminosisis D persists in obese patients undergoing bariatric surgery, despite various vitamin D supplementation regimens. Further research is needed to determine the optimal vitamin D dose to reach desirable 25(OH)D levels in this population, and to demonstrate whether this dose varies according to the surgical procedure.
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Affiliation(s)
- Marlene Toufic Chakhtoura
- Division of Endocrinology, Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon; Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon.
| | - Nancy N Nakhoul
- Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon; Division of Endocrinology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Khaled Shawwa
- Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon
| | - Christos Mantzoros
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ghada A El Hajj Fuleihan
- Division of Endocrinology, Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon
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Sakhaee K, Poindexter J, Aguirre C. The effects of bariatric surgery on bone and nephrolithiasis. Bone 2016; 84:1-8. [PMID: 26679435 PMCID: PMC4827266 DOI: 10.1016/j.bone.2015.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/13/2015] [Accepted: 12/04/2015] [Indexed: 12/25/2022]
Abstract
The impact of bariatric surgery on cardiovascular and diabetic complications associated with an improvement in survival has overshadowed the adverse skeletal health and development of kidney stone disease in this population. All longitudinal based studies in the literature reporting the incidence of bone fractures or kidney stones following bariatric surgery were reviewed. Moreover, all publications over the past decade which assessed changes in bone mineral density and bone quality, or explored underlying pathophysiologic mechanisms of bone and kidney stone disease were carefully reviewed. This review provides sufficient data to support that osteoporotic fractures and kidney stone disease are associated with Roux-en-Y gastric bypass surgery. However, due to the limited data available to date, no definitive conclusion could yet be drawn whether sleeve gastrectomy or adjustable gastric banding is associated with bone fractures and kidney stones. Bariatric surgery has emerged as the most effective and sustained treatment for weight reduction. This treatment modality has been recognized to diminish the risk of cardiovascular morbidity and mortality and ameliorate diabetes mellitus complications. The derangement in mineral metabolism has emerged as a major complication following bariatric surgery.
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Affiliation(s)
- Khashayar Sakhaee
- Department of Internal Medicine, Division of Mineral Metabolism, Charles & Jane Pak Center for Mineral Metabolism & Clinical Research,University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - John Poindexter
- Department of Internal Medicine, Division of Mineral Metabolism, Charles & Jane Pak Center for Mineral Metabolism & Clinical Research,University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Crystal Aguirre
- Department of Internal Medicine, Division of Mineral Metabolism, Charles & Jane Pak Center for Mineral Metabolism & Clinical Research,University of Texas Southwestern Medical Center, Dallas, TX, United States
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Frederiksen KD, Hanson S, Hansen S, Brixen K, Gram J, Jørgensen NR, Støving RK. Bone Structural Changes and Estimated Strength After Gastric Bypass Surgery Evaluated by HR-pQCT. Calcif Tissue Int 2016; 98:253-62. [PMID: 26661530 DOI: 10.1007/s00223-015-0091-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/20/2015] [Indexed: 11/27/2022]
Abstract
Roux-en-Y gastric bypass surgery (RYGB) is an effective treatment of morbid obesity, with positive effects on obesity-related complications. The treatment is associated with bone loss, which in turn might increase fracture risk. The aim of this study was to evaluate changes in bone mineral density (BMD) and bone architecture assessed using dual-energy X-ray absorptiometry (DXA) and high-resolution peripheral quantitative computed tomography (HR-pQCT), 6 and 12 months after RYGB, and correlate them to changes in selected biochemical markers. A prospective cohort study included 25 morbidly obese patients (10 males, 15 females). Patients were examined with DXA of the hip and spine, HR-pQCT of radius and tibia, and blood sampling before and 6 and 12 months after RYGB. Patients lost in average 33.5 ± 12.1 kg (25.8 ± 8.5 %) in 12 months. In tibia, we found significant loss of total, cortical and trabecular volumetric BMD after 12 months (all p < 0.001). Microarchitectural changes involved lower trabecular number, increased trabecular separation, and network inhomogeneity along with thinning of the cortex. Estimated bone failure load was decreased after 12 months (p = 0.005). We found only minor changes in radius. Results demonstrate significant alterations of bone microarchitecture suggesting an accelerated endosteal resorption along with disintegration of the trabecular structure which resulted in a loss of estimated bone strength in tibia. Such changes may underlie the recently reported increased risk of fracture in bariatric patients after surgery. We only observed bone structural changes in the weight-bearing bone, which indicates that mechanical un-loading is the primary mediator.
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Affiliation(s)
- Katrine Diemer Frederiksen
- Department of Endocrinology, Odense University Hospital, Kløvervænget 6, 1.sal, 5000, Odense C, Denmark.
| | - Stine Hanson
- Department of Endocrinology, Odense University Hospital, Kløvervænget 6, 1.sal, 5000, Odense C, Denmark
| | - Stinus Hansen
- Department of Endocrinology, Odense University Hospital, Kløvervænget 6, 1.sal, 5000, Odense C, Denmark
- Institute of Clinical Research, University of Southern Denmark, J.B. Winsløwsvej 19, 5000, Odense C, Denmark
| | - Kim Brixen
- Department of Endocrinology, Odense University Hospital, Kløvervænget 6, 1.sal, 5000, Odense C, Denmark
| | - Jeppe Gram
- Department of Endocrinology, Hospital of Southwest Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Niklas Rye Jørgensen
- Institute of Clinical Research, University of Southern Denmark, J.B. Winsløwsvej 19, 5000, Odense C, Denmark
- Research Center for Ageing and Osteoporosis, Department of Clinical Biochemistry, Rigshospitalet, Ndr. Ringvej 57, 2600, Glostrup, Denmark
| | - René Klinkby Støving
- Department of Endocrinology, Odense University Hospital, Kløvervænget 6, 1.sal, 5000, Odense C, Denmark
- Center for Eating Disorders, Odense University Hospital, Kløvervænget 6, 8. sal, 5000, Odense C, Denmark
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Worm D, Madsbad S, Kristiansen VB, Naver L, Hansen DL. Changes in Hematology and Calcium Metabolism After Gastric Bypass Surgery--a 2-Year Follow-Up Study. Obes Surg 2015; 25:1647-52. [PMID: 25585613 DOI: 10.1007/s11695-014-1568-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Concerns regarding nutritional deficiencies have recently emerged after Roux-en-Y gastric bypass (RYGB). METHODS A total of 835 subjects underwent RYGB, age 43.3 years, body mass index (BMI) 47.2 kg/m(2). Hematological and calcium metabolic variables were measured before, 6, 12, and 24 months after surgery. Daily supplement of 800 mg calcium, 800 U vitamin D, a multivitamin, and a vitamin B12 injection (1 mg) every third month was recommended. In subjects with low ferritin and decreasing hemoglobin levels, oral, or intravenous iron was administered. RESULTS Hemoglobin concentration decreased from before surgery to month 24 for both men (9.3 ± 0.05 vs. 8.3 ± 0.08 mmol/L, p < 0.001) and women (8.4 ± 0.03 vs. 7.7 ± 0.06 mmol/L, p < 0.001). At 24 months, anemia was present in 25.8 % of women and 22.1 % of men. Predictors of anemia in both sexes were baseline hemoglobin (p < 0.001), excessive weight loss in men, and younger age in women (p < 0.001). Plasma ferritin levels decreased in both sexes (p < 0.01), whereas concentrations of folic acid and vitamin B12 increased from before surgery to 24 months after surgery (p < 0.001). Vitamin D increased from baseline to month 24 in both sexes (p < 0.01). In women, PTH increased from baseline to month 24 (p < 0.05) with no changes in calcium or magnesium. CONCLUSIONS Supplementation of calcium and vitamin D was sufficient. Iron substitution did not prevent anemia, which especially affected premenopausal women. More attention should be given to iron substitution after RYGB.
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Affiliation(s)
- Dorte Worm
- Department of Internal Medicine, Køge Hospital, Lykkebækvej 1, 4600, Køge, Denmark,
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Lu CW, Chang YK, Chang HH, Kuo CS, Huang CT, Hsu CC, Huang KC. Fracture Risk After Bariatric Surgery: A 12-Year Nationwide Cohort Study. Medicine (Baltimore) 2015; 94:e2087. [PMID: 26632892 PMCID: PMC4674195 DOI: 10.1097/md.0000000000002087] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Bariatric surgery has been shown to impair bone health. This study aimed to investigate the fracture risk in patients after bariatric surgery versus propensity score-matched controls. The authors used the National Health Insurance Research Database of Taiwan and identified 2064 patients who underwent bariatric surgery during 2001 to 2009. These patients were matched to 5027 obese patients who did not receive bariatric surgery, using propensity score matching accounting for age, sex, Charlson Comorbidity Index, diabetes, hypertension, hyperlipidemia and the year morbid obesity was diagnosed. The authors followed the surgical and control cohorts to death, any diagnosis of fracture, or December 31, 2012, whichever occurred first. Cox proportional hazard regression models were used to calculate relative rates of fractures in the surgical group and control group. At the end of the 12-year study period, there were 183 fractures in the surgical group (mean follow-up 4.8 years) and 374 fractures in the matched control group (mean follow-up 4.9 years). Overall, there was a 1.21-fold [95% confidence interval (CI): 1.02-1.43] significantly increased risk of fracture in the surgical group compared with the control group. Stratified by surgical procedures, malabsorptive procedures showed a significantly higher fracture risk (1.47, 95% CI: 1.01-2.15). The Kaplan-Meier estimated fracture rates were 1.60% at 1 year, 2.37% at 2 years, 1.69% at 5 years, and 2.06% after 5 years for the surgical patients, compared with 1.51%, 1.65%, 1.53%, and 1.42%, respectively, for the matched controls. Adjusted analysis showed a trend towards an increased fracture risk, 1 to 2 years after bariatric surgery. (1.42, 95% CI: 0.99-2.05). Bariatric surgery was significantly associated with an increased risk of fractures, mainly with malabsorptive procedures, with a trend of an increased fracture risk 1 to 2 years after surgery. These results provide further evidence for the adverse effects of bariatric surgery on the risk of fractures.
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Affiliation(s)
- Chia-Wen Lu
- From the Department of Family Medicine, National Taiwan University Hospital, Taipei (C-WL, H-HC, C-SK, K-CH); Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County (Y-KC, C-TH, C-CH, K-CH); Department of Family Medicine, College of Medicine, National Taiwan University, Taipei (K-CH); Department of Health Services Administration, China Medical University, Taichung City (C-CH); and Institute of Clinical Medicine, National Yang Ming University, Taipei, Taiwan (C-CH)
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Adamczyk P, Bužga M, Holéczy P, Švagera Z, Šmajstrla V, Zonča P, Pluskiewicz W. Bone mineral density and body composition after laparoscopic sleeve gastrectomy in men: A short-term longitudinal study. Int J Surg 2015; 23:101-7. [PMID: 26408948 DOI: 10.1016/j.ijsu.2015.09.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/04/2015] [Accepted: 09/17/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Longitudinal changes in bone and body composition occurring in obese men after laparoscopic sleeve gastrectomy (LSG) has been evaluated. METHODS In short-term longitudinal study, 25 obese men in mean baseline age 44.8 ± 10.9 years and mean body mass index (BMI) 43.3 ± 4.4 kg/m(2)were assessed after undergoing LSG for obesity. Bone mineral density (BMD) (spine, femoral neck [FN], total hip [TH], and total body [TB]) and body composition (TB bone mineral content [BMC], fat, % of fat, lean, lean BMC, total mass) were assessed at baseline, and after three and six months. RESULTS Mean body measurements, including weight, BMI, waist and hips, decreased significantly over the study period (p < 0.0001). FN BMD (p < 0.01) and TH BMD (p < 0.001) decreased, and spine BMD increased significantly (p < 0.001). TB BMD did not change. Weight decreased by 21.3 ± 7.3%, BMI by 21.2 ± 7.3%, FN BMD by 3.32 ± 6.35%, TH BMD by 3.51 ± 3.95% whereas spine BMD increased by 2.89 ± 5.1%. TB BMC increased by 2.4 ± 4.62%; all other variables relating to body composition decreased: fat by 33.0 ± 9.6%, lean mass by 12.8 ± 6.1%, lean BMC by 12.3 ± 5.9%, total mass by 20.1 ± 6.4%, and % fat by 15.8 ± 7.2%. CONCLUSIONS After LSG, body size and variables related to body composition (except for TB BMC) decreased with an accompanying decrease in FN BMD in the men in this study. Spine BMD increased, and TB BMD did not change.
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Affiliation(s)
- Piotr Adamczyk
- Chair and Clinical Department of Pediatrics, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Marek Bužga
- University of Ostrava, Department of Physiology, Medical Faculty, Ostrava, Czech Republic
| | - Pavol Holéczy
- University of Ostrava, Department of Surgical Disciplines, Medical Faculty, Czech Republic
| | - Zdeněk Švagera
- University of Ostrava, Department of Biomedical Sciences, Faculty of Medicine, Ostrava, Czech Republic
| | - Vít Šmajstrla
- Bone Densitometry Laboratory, Bormed, Ostrava, Czech Republic
| | - Pavel Zonča
- University of Ostrava, Department of Surgical Disciplines, Medical Faculty, Czech Republic
| | - Wojciech Pluskiewicz
- Chair of Internal Medicine, Diabetology and Nephrology, Metabolic Bone Diseases Unit, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland.
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Schafer AL, Weaver CM, Black DM, Wheeler AL, Chang H, Szefc GV, Stewart L, Rogers SJ, Carter JT, Posselt AM, Shoback DM, Sellmeyer DE. Intestinal Calcium Absorption Decreases Dramatically After Gastric Bypass Surgery Despite Optimization of Vitamin D Status. J Bone Miner Res 2015; 30:1377-85. [PMID: 25640580 PMCID: PMC4593653 DOI: 10.1002/jbmr.2467] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/04/2015] [Accepted: 01/26/2015] [Indexed: 12/13/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) surgery has negative effects on bone, mediated in part by effects on nutrient absorption. Not only can RYGB result in vitamin D malabsorption, but the bypassed duodenum and proximal jejunum are also the predominant sites of active, transcellular, 1,25(OH)2 D-mediated calcium (Ca) uptake. However, Ca absorption occurs throughout the intestine, and those who undergo RYGB might maintain sufficient Ca absorption, particularly if vitamin D status and Ca intake are robust. We determined the effects of RYGB on intestinal fractional Ca absorption (FCA) while maintaining ample 25OHD levels (goal ≥30 ng/mL) and Ca intake (1200 mg daily) in a prospective cohort of 33 obese adults (BMI 44.7 ± 7.4 kg/m(2)). FCA was measured preoperatively and 6 months postoperatively with a dual stable isotope method. Other measures included calciotropic hormones, bone turnover markers, and BMD by DXA and QCT. Mean 6-month weight loss was 32.5 ± 8.4 kg (25.8% ± 5.2% of preoperative weight). FCA decreased from 32.7% ± 14.0% preoperatively to 6.9% ± 3.8% postoperatively (p < 0.0001), despite median (interquartile range) 25OHD levels of 41.0 (33.1 to 48.5) and 36.5 (28.8 to 40.4) ng/mL, respectively. Consistent with the FCA decline, 24-hour urinary Ca decreased, PTH increased, and 1,25(OH)2 D increased (p ≤ 0.02). Bone turnover markers increased markedly, areal BMD decreased at the proximal femur, and volumetric BMD decreased at the spine (p < 0.001). Those with lower postoperative FCA had greater increases in serum CTx (ρ = -0.43, p = 0.01). Declines in FCA and BMD were not correlated over the 6 months. In conclusion, FCA decreased dramatically after RYGB, even with most 25OHD levels ≥30 ng/mL and with recommended Ca intake. RYGB patients may need high Ca intake to prevent perturbations in Ca homeostasis, although the approach to Ca supplementation needs further study. Decline in FCA could contribute to the decline in BMD after RYGB, and strategies to avoid long-term skeletal consequences should be investigated.
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Affiliation(s)
- Anne L Schafer
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Connie M Weaver
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Dennis M Black
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Amber L Wheeler
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Hanling Chang
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Gina V Szefc
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Lygia Stewart
- Department of Surgery, University of California, San Francisco, CA, USA
- Surgical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Stanley J Rogers
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Jonathan T Carter
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Andrew M Posselt
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Dolores M Shoback
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Carrasco F, Basfi-Fer K, Rojas P, Valencia A, Csendes A, Codoceo J, Inostroza J, Ruz M. Changes in bone mineral density after sleeve gastrectomy or gastric bypass: relationships with variations in vitamin D, ghrelin, and adiponectin levels. Obes Surg 2015; 24:877-84. [PMID: 24435517 DOI: 10.1007/s11695-014-1179-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND A major long-term concern after gastric bypass (GBP) is the risk of osteoporosis; however, little is known about this complication in patients undergoing sleeve gastrectomy (SG). OBJECTIVE To evaluate changes in bone mineral density (BMD) after GBP and SG, and its relationship with changes in vitamin D, parathyroid hormone (PTH), ghrelin, and adiponectin. METHODS Twenty-three women undergoing GBP (BMI 42.0 ± 4.2 kg/m2; 37.3 ± 8.1 years) and 20 undergoing SG (BMI 37.3 ± 3.2 kg/m2; 34.2 ± 10.2 years) were studied before and 6 and 12 months after surgery. BMD was measured by dual-energy X-ray absorptiometry. Plasma PTH, 25-hydroxyvitamin D (25-OHD), ghrelin, and adiponectin concentrations were determined. Food as well as calcium and vitamin D supplement intake was recorded. RESULTS Excess weight loss (mean ± SE), adjusted by baseline excess weight, was 79.1±3.8% and 74.9 ± 4.1% 1 year after GBP and SG, respectively (p = 0.481). Significant reduction in BMD for total body (TB), lumbar spine (LS), and femoral neck (FN) was observed after GBP. In the SG group, reduction in BMD was significant only for TB. Adjusted by baseline BMD, the difference between change in BMD for GBP vs. SG was not significant for TB, LS, or FN. Percent reduction in ghrelin concentration was a main factor related to total BMD loss (GBP group) and LS BMD loss (GBP and SG groups). CONCLUSIONS One year after gastric bypass, bone mineral density was significantly affected, mainly at the femoral neck. Decreases in bone mineral density were more dramatic among patients who had greater baseline BMD and greater reduction in ghrelin concentrations.
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Affiliation(s)
- Fernando Carrasco
- Department of Nutrition, Faculty of Medicine, University of Chile, Independencia 1027, 8380453, Santiago, Chile
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Abstract
Osteoporosis is a skeletal disease characterized by decreased bone mass and microarchitectural changes in bone tissue that increase the susceptibility to fracture. Secondary osteoporosis is loosely defined as low bone mineral density or increased risk of fragility fracture caused by any factor other than aging or postmenopausal status. The purpose of this review is to discuss the current understanding of the pathophysiology and contribution to fracture risk of many of the more common causes of secondary osteoporosis, as well as diagnostic considerations, outlined by organ system. While not comprehensive, included are a wide array of diseases, conditions, and medications that have been associated with bone loss and susceptibility to fractures. The hope is to highlight the importance to the general clinician of screening for and treating the osteoporosis in these patients, so to limit the resultant increased morbidity associated with fractures.
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Affiliation(s)
- Gregory R Emkey
- Pennsylvania Regional Center for Arthritis & Osteoporosis Research, 1200 Broadcasting Road, Suite 200, Wyomissing, PA 19610, USA.
| | - Sol Epstein
- Mt Sinai School of Medicine, I Gustave Levy Place New York, New York, NY, USA
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Scibora LM. Skeletal effects of bariatric surgery: examining bone loss, potential mechanisms and clinical relevance. Diabetes Obes Metab 2014; 16:1204-13. [PMID: 25132010 DOI: 10.1111/dom.12363] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/27/2014] [Accepted: 07/29/2014] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is the most effective therapeutic approach to morbid obesity, resulting in substantial weight loss and improved cardiometabolic profiles; however, a growing body of evidence suggests that bariatric procedures increase both skeletal fragility and the risk of related future fracture secondary to excessive bone loss. Prospective evidence shows that areal bone mineral density (BMD) assessed by dual energy X-ray absorptiometry (DXA) declines by as much as 14% in the proximal femoral regions, including the femoral neck and total hip, 12 months postoperatively. Lumbar spine areal BMD outcomes show greater 12-month postoperative variability across surgical procedures (-8 to +6%) and contrast with no change in volumetric BMD outcomes measured by quantitative computed tomography. Diminished mechanical loading, micronutrient deficiency and malabsorption, along with neurohormonal alterations, offer plausible underlying mechanisms to explain these observed post-bariatric bone changes, but most remain largely unsubstantiated in this population. Importantly, DXA-based skeletal imaging may have limited utility in accurately detecting bone change in people undergoing bariatric surgery; partly because excessive tissue overlying bone increases the variability of areal BMD outcomes. Moreover, a paucity of fracture and osteoporosis incidence data raises questions about whether marked post-bariatric surgery bone loss is clinically relevant or a functional adaptation to skeletal unloading. Future studies that use technology which is able to accurately capture the site-specific volumetric BMD and bone architectural changes that underpin bone strength in people undergoing bariatric surgery, that consider mechanical load, and that better quantify long-term fracture and osteoporosis incidence are necessary to understand the actual skeletal effects of bariatric surgery.
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Affiliation(s)
- L M Scibora
- Health and Human Performance Department, University of St. Thomas, St. Paul, MN, USA
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Effect of bariatric surgery on bone mineral density: comparison of gastric bypass and sleeve gastrectomy. Obes Surg 2014; 23:2086-91. [PMID: 23818239 DOI: 10.1007/s11695-013-1016-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of our study was to compare bone mineral density (BMD) a year after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in age- and body mass index-matched women. In 33 morbidly obese women undergoing RYGB and 33 undergoing SG, plasma determinations of calcium, parathyroid hormone (PTH), 25-hydroxyvitamin D (25(OH) D3), and insulin-like growth factor-I (IGF-I) were made prior to and at 12 months after surgery. Dual-energy X-ray absorptiometry was performed in all patients 1 year after surgery. BMD at the femoral neck and the lumbar spine 1 year after surgery was similar in women undergoing RYGB and SG (1.01 ± 0.116 vs. 1.01 ± 0.122 g/cm(2), p = 0.993; 1.05 ± 0.116 vs. 1.08 ± 0.123 g/cm(2), p = 0.384). The percentage of patients with osteopenia and osteoporosis was not different between groups. In the linear regression analysis, age (β = -0.628, p = 0.034) and lean mass 12 months after surgery (β = 0.424, p = 0.021) were found to be the main determinants of femoral neck BMD. Age (β = -0.765, p = 0.025), menopause (β = -0.898, p = 0.033), and lean mass (β = 0.615, p = 0.023) were determinants of BMD at the lumbar spine. No influence was found between low bone mass and type of surgery, plasma PTH, 25(OH) D3, or IGF-I. The effect of RYGB and SG on BMD was comparable a year after surgery. Menopausal women were at a higher risk of having low bone mass, but the presence of osteoporosis was uncommon.
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Obinwanne KM, Riess KP, Kallies KJ, Mathiason MA, Manske BR, Kothari SN. Effects of laparoscopic Roux-en-Y gastric bypass on bone mineral density and markers of bone turnover. Surg Obes Relat Dis 2014; 10:1056-62. [PMID: 25443074 DOI: 10.1016/j.soard.2014.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 06/04/2014] [Accepted: 06/07/2014] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite multiple beneficial effects of weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGB), the influence on bone mineral density (BMD) remains largely unknown. Our objective was to evaluate the changes in BMD and serum/urine bone markers after LRYGB. METHODS Thirty-four women undergoing LRYGB were prospectively enrolled and underwent bone densitometry and serum/urine analysis preoperatively and 1 year postoperative. Changes≥.025 g/cm(2) in hip, femoral neck, and spine BMD and decreases>2% in total BMD were considered significant. Statistical analysis included paired t tests and McNemar's test. RESULTS Mean age was 44.6 years. Body mass index at the preoperative and 1-year postoperative intervals were 46.7 and 29.6 kg/m(2), respectively. Mean hip, femoral neck, and spine (L1-L4) BMD was 1.191 versus 1.087 g/cm(2) (P< .001), 1.105 versus 1.032 g/cm(2) (P< .001), and 1.323 versus 1.277 g/cm(2) (P< .001) at the preoperative and 1 year postoperative intervals, respectively. Mean total BMD decreased from 1.328 preoperatively to 1.251 g/cm(2) at 1 year postoperative (P<.001). The decreases in BMD were 5.8%, 6.5%, 3.5%, and 8.8% for hip, femoral neck, spine (L1-L4) and total BMD from preoperative to 1 year postoperative. The proportion of patients with low vitamin D levels decreased from 55% preoperatively to 21% at 1 year postoperative (P = .004). Elevated osteocalcin and bone alkaline phosphatase was observed in 4% and 63% (P<.001), and 14% and 41% (P = .011) of patients preoperatively and at 1 year postoperative, respectively. CONCLUSION BMD and bone markers changed significantly after LRYGB. Current recommendations for supplementation in post-LRYGB women may need to be reevaluated.
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Affiliation(s)
- Kosisochi M Obinwanne
- Minimally Invasive Bariatric Surgery and Advanced Laparoscopy Fellowship, Gundersen Health System, La Crosse, Wisconsin
| | - Kevin P Riess
- Department of Surgery, Essentia Health, Duluth, Minnesota
| | - Kara J Kallies
- Department of Research, Gundersen Medical Foundation, La Crosse, Wisconsin
| | | | - Brian R Manske
- Department of Radiology, Gundersen Health System, La Crosse, Wisconsin
| | - Shanu N Kothari
- Department of General and Vascular Surgery, Gundersen Health System, La Crosse, Wisconsin.
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Yu EW. Bone metabolism after bariatric surgery. J Bone Miner Res 2014; 29:1507-18. [PMID: 24677277 PMCID: PMC4128478 DOI: 10.1002/jbmr.2226] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/07/2014] [Accepted: 03/12/2014] [Indexed: 12/24/2022]
Abstract
Bariatric surgery is a popular and effective treatment for severe obesity but may have negative effects on the skeleton. This review summarizes changes in bone density and bone metabolism from animal and clinical studies of bariatric surgery, with specific attention to Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and sleeve gastrectomy (SG). Skeletal imaging artifacts from obesity and weight loss are also considered. Despite challenges in bone density imaging, the preponderance of evidence suggests that bariatric surgery procedures have negative skeletal effects that persist beyond the first year of surgery, and that these effects vary by surgical type. The long-term clinical implications and current clinical recommendations are presented. Further study is required to determine mechanisms of bone loss after bariatric surgery. Although early studies focused on calcium/vitamin D metabolism and mechanical unloading of the skeleton, it seems likely that surgically induced changes in the hormonal and metabolic profile may be responsible for the skeletal phenotypes observed after bariatric surgery.
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Affiliation(s)
- Elaine W Yu
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA
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Metabolic bone changes after bariatric surgery. Surg Obes Relat Dis 2014; 11:406-11. [PMID: 25487633 DOI: 10.1016/j.soard.2014.03.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 03/11/2014] [Indexed: 11/24/2022]
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Ruiz-Tovar J, Oller I, Priego P, Arroyo A, Calero A, Diez M, Zubiaga L, Calpena R. Short- and mid-term changes in bone mineral density after laparoscopic sleeve gastrectomy. Obes Surg 2014; 23:861-6. [PMID: 23315187 DOI: 10.1007/s11695-013-0866-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bariatric surgery is the most effective treatment for achieving a significant weight loss. Morbidities present a significant reduction after bariatric surgery, but it may also result in several health complications, related to nutritional deficiencies, including bone metabolism. Several studies have reported a decrease in bone mineral density (BMD), but most of them referring to malabsorptive procedures. Restrictive procedures do not imply changes in gastrointestinal anatomy, so that one may expect fewer metabolic disturbances. METHODS We performed a retrospective observational study of all morbidly obese patients undergoing LSG between 2008 and 2011 at our institution. Bone densitometry was performed before surgery and 1 and 2 years after the intervention. Body size measurements, analytical variables and densitometric values in the lumbar spine (BMD, t score and z score) were investigated. RESULTS Forty-two patients were included, 39 females and 3 males. Mean BMI was 51.21 kg/m(2). Mean excessive BMI loss was 79.9 % after 1 year and 80.6 % after 2 years. Mean BMD values for spine increased progressively, reaching statistical significance at 1 and at 2 years. Percentage of BMD increase was 5.7 % at 1 year and 7.9 % at 2 years. An inverse correlation was observed between BMD increase and parathyroid hormone (PTH) decrease and a direct correlation between BMD and vitamin D increase. CONCLUSION Bone mineral density showed a progressive increase during the first and second year after sleeve gastrectomy. BMD changes are not associated with weight loss, but showed a direct correlation with vitamin D and an inverse correlation with PTH levels.
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Affiliation(s)
- Jaime Ruiz-Tovar
- Department of Surgery, Bariatric Surgery Unit, General University Hospital Elche, University Miguel Hernandez, Elche, Alicante, Spain.
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Biagioni MFG, Mendes AL, Nogueira CR, Paiva SA, Leite CV, Mazeto GM. Weight-Reducing Gastroplasty with Roux-en-Y Gastric Bypass: Impact on Vitamin D Status and Bone Remodeling Markers. Metab Syndr Relat Disord 2014; 12:11-5. [DOI: 10.1089/met.2013.0026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
| | - Adriana L. Mendes
- Department of Internal Medicine, São Paulo State University, FMB-UNESP, Botucatu, Brazil
| | - Célia R. Nogueira
- Department of Internal Medicine, São Paulo State University, FMB-UNESP, Botucatu, Brazil
| | - Sérgio A.R. Paiva
- Department of Internal Medicine, São Paulo State University, FMB-UNESP, Botucatu, Brazil
| | - Celso V. Leite
- Department of Surgery, Botucatu Medical School, São Paulo State University, FMB-UNESP, Botucatu, Brazil
| | - Gláucia M.F.S. Mazeto
- Department of Internal Medicine, São Paulo State University, FMB-UNESP, Botucatu, Brazil
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Abstract
Bariatric surgery is an effective and increasingly common treatment for severe obesity and its many comorbidities. The side-effects of bariatric surgery can include detrimental effects on bone and mineral metabolism. Bone disease in patients who have had bariatric surgery is affected by preoperative abnormalities in bone and mineral metabolism related to severe obesity. Changes that arise after bariatric surgery are specific to procedure type: the most pronounced abnormalities in calciotropic hormones and bone loss are noted after procedures that result in the most malabsorption. The most consistent site for bone loss after all bariatric procedures is at the hip. There are limitations of dual-energy x-ray absorptiometry technology in this population, including artefact introduced by adipose tissue itself. Bone loss after bariatric surgery is probably multifactorial. Proposed mechanisms include skeletal unloading, abnormalities in calciotropic hormones, and changes in gut hormones. Few data for fracture risk in the bariatric population are available, and this is a crucial area for additional research. Treatment should be geared toward correction of nutritional deficiencies and study of bone mineral density in high-risk patients. We explore the skeletal response to bariatric surgery, potential mechanisms for changes, and strategies for management.
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Affiliation(s)
- Emily M Stein
- Columbia University College of Physicians and Surgeons, Columbia University, New York 10032, USA.
| | - Shonni J Silverberg
- Columbia University College of Physicians and Surgeons, Columbia University, New York 10032, USA
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