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Source publication
To evaluate bone metabolism, bone density (BMD) and vertebral fractures in morbidly obese individuals.
Case series of 29 premenopausal obese patients, 15 of whom had been submitted to bariatric surgery. Serum calcium, albumin, PTH and 25-hydroxy vitamin D (25OHD) were measured as well as bone densitometry of the lumbar spine and proximal femur, and...
Context in source publication
Similar publications
Objective:
This cross sectional study was undertaken to assess metabolic bone disease by examining bone mineral density (BMD), fracture prevalence, and nutritional factors pertinent to bone in a cohort >9 years post Roux-en-Y gastric bypass (RYGB).
Methods:
Fifty one subjects 9.4-36.0 years (mean 17.0 +8.1) post RYGB provided a focused history....
Citations
... Thirteen articles [26,27,32,34,35,37,38,[40][41][42][44][45][46] analyzed the relationship between bariatric surgery and femoral neck BMD. As mentioned above, there were two articles from the same database. ...
... Among the 12 articles assessing the association between femoral neck and bariatric surgery, there was one [27] article in which the average age of the subjects was less than 30 years; 5 [32,35,37,41,44] articles included 30to 40-year-old patients; and 6 [34,38,40,42,45,46] articles included patients older than 40 years of age. There was no significant heterogeneity among studies including 30-to 40-year-old patients (I 2 = 12%), so the fixedeffects model was adopted. ...
... The low heterogeneity in the subgroup analysis examining age supports this explanation. Among the 15 articles evaluating the relationship between bariatric surgery and the lumbar spine, there were 2 [26,28] articles in which the average age of subjects was less than 30 years; 6 [32,34,35,37,41,44] articles included 30-to 40-year-old patients; and 7 [29,30,34,38,40,42,45] articles included patients older than 40 years of age. The age division was not clear in one of the articles [47]; therefore, we did not include this in the subgroup analysis. ...
Keypoints
What is already known?Bariatric surgery (BS) in obese individuals has become increasingly popular.
BS can result in many complications, including osteoporosis. There are many reasons for this, including malabsorption and hormonal disorders.
It is necessary to investigate the association between BS and bone density.
What does this study add?BS had a certain impact on many parts of the body, such as the femoral neck, lumbar spine and whole body.
The impact of metabolic surgery on bone density becomes more significant in participants aged 40 or older.
The impact of BS on bone density becomes greater in the patients with a postsurgical time of greater than 12 months.
How might your results change the direction of research or the focus of clinical practice?
BS had a certain impact on many parts of the body, particularly in patients over 40 years of age and individuals with a postsurgical time of greater than 12 months. These patients should pay attention to bone density screening and osteoporosis prevention. Further research is needed to analyze the variations over a longer period.
... [13] There seems to be a direct relationship between the percentage of bone loss and the rate of weight loss. [14] It is troublesome to interpret bone condensation leads to the rapid weight loss phase due to technical errors related to reduce subcutaneous fat thickness. Since the second year after gastric bypass surgery, measuring of BMD has been the gold standard for assessing bone status. ...
Background:
Previous studies have reported that gastrectomy and fundectomy can induce osteopenia. Body fat index is a new index of obesity that shows central obesity and other risks of obesity. Sleeve gastrectomy (SG) is a bariatric surgery and a new technique introduced as subsleeve, which only resected fundus of the stomach. In this study, it has been shown the effect of subsleeve and SG on fat index and bone densitometry in an animal model.
Materials and methods:
Rabbits were underlined SG, fundectomy (surgical removal of fundus), or sham-operated (controls without any resection), and after 12 weeks, fat index and bone densitometry were obtained.
Results:
Our study showed that there was no significant difference between SG and fundectomy groups in bone mass density and fat mass after surgery in comparison with presurgery condition. SG group were associated with lower fat index and bone density, and it showed significantly decrease in weight after 1.5 months.
Conclusion:
Sub-SG did not show any significant effect on fat index and bone densitometry in comparison with SG. However, we found lower fat index in sleeve group of rabbits, but it was not statistically significant.
... The sample sizes of these studies ranged from 29 to 50704. Among them, four [20,23,29] datasets only assessed the GB procedure, and the other eight [21,22,[30][31][32][33][34][35]] evaluated more than one bariatric procedure. With regard to study design, two articles [23,35] described RCTs, and the rest [20][21][22][29][30][31][32][33][34] were retrospective cohort studies. ...
... Among them, four [20,23,29] datasets only assessed the GB procedure, and the other eight [21,22,[30][31][32][33][34][35]] evaluated more than one bariatric procedure. With regard to study design, two articles [23,35] described RCTs, and the rest [20][21][22][29][30][31][32][33][34] were retrospective cohort studies. With regard to the data source, three [22,29,35] datasets were collected from a single institution, two datasets [22,29,35] collected data from more than one center and seven [20,[30][31][32][33][34] collected data from nation-wide or region-wide register databases. ...
... With regard to study design, two articles [23,35] described RCTs, and the rest [20][21][22][29][30][31][32][33][34] were retrospective cohort studies. With regard to the data source, three [22,29,35] datasets were collected from a single institution, two datasets [22,29,35] collected data from more than one center and seven [20,[30][31][32][33][34] collected data from nation-wide or region-wide register databases. A BMI-matched comparison was mentioned in five articles (6 datasets) [20,22,23,29,31]. ...
Objective:
Bariatric surgery (malabsorptive [i.e., biliopancreatic diversion, BPD], restrictive [i.e., sleeve gastrectomy, SG; adjustable gastric banding, AGB] and mixed [i.e., gastric bypass, GB] procedures) has been reported to be associated with an increased risk of fracture; however, which procedure poses the greatest risk of fracture is still controversial. The aim of the current meta-analysis was to investigate the degree of fracture risk after different bariatric procedures.
Material and methods:
Electronic databases, including Medline/PubMed, EMBASE and Cochrane library, were systematically searched from inception to July 11, 2019 with no language restrictions to retrieve randomized controlled trials (RCTs) or cohort studies evaluating the impact of any kind of bariatric surgery on postoperative fractures in patients with obesity. Pairwise meta-analysis and Bayesian network meta-analysis were performed to pool the outcome estimates of interest, including fracture incidence and fracture risk. The values of the surface under the cumulative ranking (SUCRA) probability for fracture risk were calculated and sorted according to the different surgical procedures.
Results:
A total of twelve studies published between 2010 and 2019, comprising 159,916 participants with obesity were identified for the analysis. The incidence of fracture increased from 3% (95% confidence interval [CI] 2 - 4%) in patients with non-surgical intervention (drug treatment, alteration in life style and diet control) to 5% (95% CI 4 - 7%) in those who had undergone bariatric surgery (pooled relative risk [RR] = 1.41 95% CI: 1.22 - 1.63). Network meta-analysis revealed that based on the SUCRA ranking of the different surgical procedures, the malabsorptive procedure had the highest possibility of increased fracture risk in patients with obesity (74.75%), followed by the mixed procedures (73.85%), nonsurgical intervention (43.55%) and the restrictive procedure (7.85%); for different surgery types. The BPD group had the highest possibility of increased fracture risk (99.49%), followed by the GB (74.92%), nonsurgical intervention (44.49%), AGB (26.64%) and SG (4.45%) groups.
Conclusions:
Significant differences exist among different bariatric surgeries impacting on fracture risk. The malabsorptive and mixed procedures, but not the restrictive procedure, increase the postoperative risk of fracture. Considering the weight-reduction effects and fracture risk, the sleeve gastrectomy procedure may be the best choice for patients with obesity, especially those who are susceptible to osteoporosis.
... However, in malabsorptive procedures, nutrient deficiency and secondary hyperparathyroidism probably play a significant role. Low serum 25OHD levels and poor absorption of calcium seem to be related to secondary hyperparathyroidism observed in women who had undergone RYGB [122], and there is association between changes in the cortical bone parameters and changes in PTH post-surgery [112]. A 6-month prospective clinical trial in obese patients who underwent RYGB showed a decrease in Ca absorption without alteration of the Ca-PTH axis, suggesting the implication of other regulating hormones [123]. ...
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.
... A plausible mechanism may be a direct effect of adipokines, namely leptin, on PTH secretion as leptin has been shown to be a PTH secretagogue. [22][23][24] In 2040 general population cohort of healthy subjects without established cardiovascular disease and not taking antihypertensive drugs, PTH was a significant predictor of LVMI in males and females, older and younger than 60 years of age, respectively [P < .01, <.05]. ...
Abstract
Introduction: LVH confers an increased risk of cardiovascular and all-cause mortality. Obesity and hypertension are considered important factors in the development and extent of left ventricular hypertrophy. A relation between LVH and PTH has been demonstrated in patients with 1ry and 2ry hyperparathyroidism, hypertension, and general population. The aim of this work was to study the role of PTH as a determinant of LV mass in hypertensive and / or obese patients.
Subjects and methods: The study included 85 subjects, classified into 3 groups, group I: 30 obese hypertensive patients, group II: 30 obese non-hypertensive patients, and group III: 25 healthy matched control group. Waist and hip circumferences were measured, Body fat mass percentage and BMI was calculated. Renal function tests: serum creatinine and blood urea, total calcium, and phosphorus. Serum parathormone level was also measured by using radioimmunoassay method. Using echocardiography, left ventricular mass was calculated and was indexed to body surface area.
Results: In both group I and group II, significantly higher levels of serum PTH [P= 0.005, 0.044 for groups I, II respectively] along with significantly higher LVMI [P= <0.001, <0.001 for groups I, II respectively] compared to healthy subjects. A significant positive correlation was found between serum PTH and left ventricular mass index in the three studied groups [P= <0.001, <0.001, 0.005 for groups I, II, and III respectively]. There was no statistically significant difference in serum calcium among the three studied groups [P= 0.394].
Conclusion: PTH is strongly related to LVMI in obese patients with or without hypertension as well as normal individuals, independent of Ca 2+ and blood pressure. To the best of our knowledge, our study is the first to suggest obesity related secondary hyperparathyroidism as a novel mechanism to explain obesity cardiomyopathy.
... Table 1 shows the methodological characteristics of the selected studies. Of the five articles, three corresponded to prospective cohort studies; [18][19][20][21][22] two used the laparoscopic approach and one enrolled only women; there was one case report and one case series. All assessed the nutritional status and bone fractures, routes of administration, as well as the respective dosage of vitamin D and calcium; one article evaluated the parathyroid hormone and its influence on bone reabsorption in RYGB. ...
... Research investigated women in pre-and postmenopausal stages demonstrating that there was no critical difference between them in calcium absorption inadequacy and even the differences in relationship to the sort of surgery were not present. 17,18,23 As per this review, the sort of administration and dosage had no relationship or significance over time on drug treatment. Nonetheless, no direct connection to the postoperative bone loss was demonstrated. ...
Introduction: Bariatric surgery is viewed as the best tool for the control and treatment of severe obesity; however, postsurgery, they have a greater risk of developing nutritional deficiencies as this procedure hinders the absorption of most of the nutrients. Objective: To evaluate the effect of vitamin D insufficiency and that of calcium in bone in patients after Roux-en-Y gastric bypass (RYGB), and the mode of administration of calcium, its dosage, and efficacy. Materials and methods: A precise survey was performed with articles identified that are associated with the subject of interest. Articles from 10 years back were looked up in PubMed, the US National Library of Medicine, the National Institutes of Health, Medline, Lilacs, Scielo, and Cochrane utilizing the headings “bariatric surgery,” “bone,” “obesity,” “vitamin D,” “calcium,” and “absorption.” Results: Five articles were incorporated into this survey that have analyzed the facts that bariatric surgery can cause wholesome inadequacies of nutrition and poor assimilation of fats and fat-dissolvable vitamins and micronutrients, e.g., calcium. Conclusion: Patients submitted to RYGB should make use of multivitamins and minerals, especially vitamin D and calcium to prevent bone fractures. Monitoring, treatment, and control of risk factors are essential to prevent complications after this operation. © 2018, Jaypee Brothers Medical Publishers (P) Ltd. All rights reserved.
... The negative influence of weight loss and the hormonal and biochemical changes induced by bariatric surgery on bone health has been reported [7,11,20,[31][32][33][34][35], in addition to the association between excess body weight loss and bone mineral density (BMD) 1 to 2 years after RYGB [20,34,36]. Bone turnover increased in the study sample, evidence by higher CTX and BSAP after RYGB. ...
Purpose:
Bariatric surgery has been associated with bone remodeling changes. The action of adipokines on the expression of receptor activator of nuclear factor kappa β ligand (RANKL) and osteoprotegerin (OPG) and on an increase in sclerostin could be related to these changes.
Materials and methods:
This study aimed to assess the repercussions of weight loss, fat mass (FM), and fat-free mass (FFM) loss and biochemical and hormonal changes on bone remodeling markers after Roux-en-Y gastric bypass (RYGB). Anthropometric data, parathyroid hormone (PTH), bone-specific alkaline phosphatase (BSAP), collagen type 1 C-telopeptide (CTX), 25-hydroxy vitamin D (25-OH-VitD), leptin, adiponectin, RANKL, OPG, and sclerostin of 30 menstruating women were measured preoperatively (Pre), and 3, 12, and 24 months (m) after RYGB.
Results:
Leptin (34.4 (14.7; 51.9) vs. 22.5 (1.9; 52.7) ng/mL) and OPG (3.6 (1.1; 11.5) vs. 3.4 (1.5; 6) pmol/L) decreased, and adiponectin (7.4 (1.7; 18.4) vs. 13.8 (3.0; 34.6) μg/mL), CTX (0.2 (0.1; 2.2) vs. 0.6 (0.4; 6.0) ng/mL), RANKL (0.1 (0.0; 0.5) vs. 0.3 (0.0; 2.0) pmol/L), and sclerostin (21.7 (3.2; 75.1) vs. 34.8 (6.4; 80.5) pmol/L) increased after 3 m. BSAP increased after 12 m (10.1 (5.4; 18.9) vs. 13.9 (6.9; 30.2) μg/mL) (p < 0.005). CTX correlated positively with adiponectin at 24 m and inversely with leptin Pre; OPG at 3 m; weight, FM, FFM, and leptin at 24 m. RANKL correlated directly with weight at 3 m. Sclerostin correlated inversely with weight Pre and FM at 3 m. BSAP correlated negatively with 25-OH-VitD at 12 m, and positively with PTH at 24 m.
Conclusions:
RYGB induced weight loss, and biochemical, hormonal, and body composition changes are associated with higher bone remodeling.
... Table 1 shows the methodological characteristics of the selected studies. Of the five articles, three corresponded to prospective cohort studies; [18][19][20][21][22] two used the laparoscopic approach and one enrolled only women; there was one case report and one case series. All assessed the nutritional status and bone fractures, routes of administration, as well as the respective dosage of vitamin D and calcium; one article evaluated the parathyroid hormone and its influence on bone reabsorption in RYGB. ...
... Research investigated women in pre-and postmenopausal stages demonstrating that there was no critical difference between them in calcium absorption inadequacy and even the differences in relationship to the sort of surgery were not present. 17,18,23 As per this review, the sort of administration and dosage had no relationship or significance over time on drug treatment. Nonetheless, no direct connection to the postoperative bone loss was demonstrated. ...
... Several authors have reported that obesity alone is a risk factor for 25OHD deficiency and secondary hyperparathyroidism, which can worsen after weight reduction in subjects who have undergone bariatric surgery [37][38][39]. Our study corroborated this fact, since 35.7 % of the operated patients exhibited secondary hyperparathyroidism due to vitamin D deficiency. ...
Summary Lower bone mineral density, vitamin D deficiency, lower lean body mass, greater loss of excess weight, and increased bone turnover are complications found after bariatric surgery correlated in the literature with increased risk of fractures. The prevention and treatment of such complications should begin immediately after surgery. Introduction The aims of the study were to evaluate bone mass in patients undergoing bariatric surgery by the Wittgrove technique after 1 year of the procedure and correlate it with body composition, weight loss, 25OH vitamin D levels, and markers of bone metabolism. Methods The operated group (OG) participated in a clinical consultation; a blood sample taken and a body composition; and bone mineral density assessment by dual energy X-ray absorptiometry (DXA). The results were compared with a control group (CG). Results Fifty-six subjects in the OG and 27 in the CG were included. The bone mineral density (BMD), after the surgery, at the lumbar spine (LS) was lower in the OG than in the CG. There was a positive correlation between total body (TB) BMD with 25OHD, body mass index (BMI), and lean mass and an inverse correlation with percentage of excess weight loss (%EWL). Vitamin D deficiency was seen in 60.41 % (OG) and in 16.6 % (CG). PTH was higher in the OG, with secondary hyperparathyroidism in 41.7 %. In 26.5 % and 14.2 % of the OG, ALP and OC levels were above the reference values. In Conclusions Lower BMD was observed, correlated with lower lean body mass and greater loss of excess weight. Vitamin D deficiency with high prevalence of secondary hyperparathyroidism and high bone turnover was detected. The prevention of bone loss should be initiated in the first months after surgery, which is a period associated with severe muscle loss and increased bone turnover.
... [240][241][242] Some state that calcium malabsorption is the direct consequence of the insufficient vitamin D supply, 243 while others show evidence of a selective calcium malabsorption independent of vitamin D status. 240,244 Some studies also report secondary hyperparathyroidism after RYGB that is independent of the vitamin D status. 235,245,246 The inconsistency of these results suggests that there may be unknown factors influencing bone metabolism after gastric bypass surgery. ...
Bariatric surgery, including the Roux-en-Y gastric bypass (RYGB), is currently the only effective long-term treatment for morbid obesity. Contrary to the traditional classification of RYGB as a restrictive and malabsorptive procedure, these factors seem to play a minor role. Increasing evidence suggests that changes in gut hormone levels, such as glucagon-like peptide-1 (GLP-1), may account for the majority of the effects.
One major side effect of RYGB surgery is a decrease in bone density. In a
longitudinal study in rats, we showed that bone mineral density decreased early after RYGB surgery and coincided with intestinal calcium malabsorption. Although intestinal calcium absorption normalized between two and seven weeks after surgery, there was no restoration of bone mass; this was potentially caused by chronic lactic acidosis. The RYGB-induced changes in bone metabolism occurred independent of weight loss.
Previous studies have shown that the compensatory decrease in energy expenditure in response to body weight loss is attenuated in RYGB rats. Since increased GLP-1 levels contribute to the reduced caloric intake after RYGB surgery, we hypothesized that they may also be involved in the reported alterations in energy expenditure; however, we did not find any effect of acute GLP-1 agonism or antagonism on energy expenditure. We were further able to show that the altered energy expenditure in RYGB rats was not caused by differences in body composition or by a shift in the thermoneutral zone.
