Fracture risk after three bariatric surgery procedures in Swedish obese subjects: up to 26 years follow‐up of a controlled intervention study

Abstract

Ahlin S, Peltonen M, Sj€ oholm K, Anveden A, Jacobson P, Andersson-Assarsson JC, Taube M, Larsson I, Lohmander LS, N€ aslund I, Svensson P-A, Carlsson LMS ). Fracture risk after three bariatric surgery procedures in Swedish obese subjects: up to 26 years follow-up of a controlled intervention study. J Intern Med 2020; 287: 546-557.Background. Previous studies have reported an increased fracture risk after bariatric surgery.Objective. To investigate the association between different bariatric surgery procedures and fracture risk.Methods. Incidence rates and hazard ratios for fracture events were analysed in the Swedish Obese Subjects study; an ongoing, nonrandomized, prospective, controlled intervention study. Hazard ratios were adjusted for risk factors for osteoporosis and year of inclusion. Information on fracture events were captured from the Swedish National Patient Register. The current analysis includes 2007 patients treated with bariatric surgery (13.3% gastric bypass, 18.7% gastric banding, and 68.0% vertical banded gastroplasty) and 2040 control patients with obesity matched on group level based on 18 variables. Median follow-up was between 15.1 and 17.9 years for the different treatment groups.Results. Duringfollow-up,the highestincidence ratefor first-time fracture was observed in the gastric bypass group (22.9 per 1000 person-years). The corresponding incidence rates were 10.4, 10.7 and 9.3 per 1000 person-years for the vertical banded gastroplasty, gastric banding and control groups, respectively. The risk of fracture was increased in the gastric bypass group compared with the control group (adjusted hazard ratio [adjHR] 2.58; 95% confidence interval [CI] 2.02-3.31; P < 0.001), the gastric banding group (adjHR 1.99; 95%CI 1.41-2.82; P < 0.001), and the vertical banded gastroplasty group (adjHR 2.15; 95% CI 1.66-2.79; P < 0.001).Conclusions. The risk of fracture is increased after gastric bypass surgery. Our findings highlight the need for long-term follow-up of bone health for patients undergoing this treatment.Fracture and bariatric surgery / S. Ahlin et al.

Bone Mineral Density, Parathyroid Hormone, and Vitamin D After Gastric Bypass Surgery: a 10-Year Longitudinal Follow-Up

“…Two studies compared the gastric bypass procedure with a restrictive procedure such as gastric banding. In these, bypass seemed to carry a greater risk for osteoporotic fractures such as hip fractures, as well as wrist fractures [15,17]. Reduction in bone mineral density does not fully explain the occurrence of wrist fractures; other risk factors could be involved including lower grip strength, increased walking speed, and increased risk for a fall outdoors [36][37][38].…”

“…Bariatric procedures, in particular those based on malabsorption, lead to a fall in bone mineral density (BMD) [9][10][11][12], an increase in bone resorption and bone remodeling, and changes in bone histomorphometry parameters [10,13,14]. The risk for fracture increases at several skeletal sites after bariatric surgery [15][16][17]. These changes in bone metabolism seem not to be the result of weight loss alone, since BMD continues to decline even when the patient's weight has stabilized [18].…”

Long-Term Effects in Bone Mineral Density after Different Bariatric Procedures in Patients with Type 2 Diabetes: Outcomes of a Randomized Clinical Trial

“…In a meta-analysis, the highest possibility of fracture was found after malabsortive procedures (biliopancreatic diversion) followed by the mixed techniques (RYGB) without an increased risk after restrictive procedures (adjustable gastric banding and SG) compared to the nonsurgical population [64]. Recently, the 26 year results of the S.O.S study [65] observed the highest incidence rate for first fracture after RYGB compared to restrictive procedures. In our cohort, the small size and time of observation were probably the reason why we had no bone fractures.…”

Glycocholic acid and butyrate synergistically increase vitamin D-induced calcium uptake in Caco-2 intestinal epithelial cell monolayers

“…Therefore, patients are advised to take lifelong vitamin D and calcium supplementation to counteract this, albeit the long-term efficacy of the prevention has still not been established. Several reports during the last years have shown negative effects of RYGB on bone mineralization, and now recently even indicate an increased risk of osteoporotic fractures, despite the supplementation therapy, which suggests that the supplementation is not effective in preventing the decreased calcium absorption and in the long-run osteoporosis ( Yu et al, 2017 ; Rousseau et al, 2016 ; Axelsson et al, 2018 ; Ahlin et al, 2020 ). It was recently reported that RYGB leads to an up to almost 80% decreased fractional calcium absorption, despite adequate vitamin D levels ( Schafer, 2017 ).…”

“…It was recently reported that RYGB leads to an up to almost 80% decreased fractional calcium absorption, despite adequate vitamin D levels ( Schafer, 2017 ). It has also been shown that the risk of osteoporotic fractures is increased in particular after RYGB more than other bariatric surgery methods, and is thus not only a consequence of the weight decrease ( Rousseau et al, 2016 ; Ahlin et al, 2020 ; Nakamura et al, 2014 ; Lu et al, 2015 ). Therefore, it is of importance to try finding mechanisms that can explain this effect, and make it possible to find treatments to reverse the decreased calcium absorption after RYGB.…”