This article is more than 5 years old. Information may no longer be current.
Fracture risk increases with bariatric surgery
Click Here to Manage Email Alerts
People with severe obesity who undergo bariatric surgery have a higher risk for fracture both before and after the procedure compared with controls with and without obesity, study data show.
“Obesity may not be as protective against fracture as was originally thought, Claudia Gagnon, PhD, FRCPC, of the endocrinology and nephrology unit at CHU de Québec Research Center in Québec City, told Endocrine Today. “This is supported by results from our study and recent evidence from the literature. Physicians should assess fracture risk in this population and address potentially modifiable risk factors (eg, vitamin D deficiency which is highly prevalent in this population). Decreased bone quality appears to have a predominant role over bone quantity in reducing bone strength in obesity.”
Claudia Gagnon
Gagnon and colleagues evaluated health care administrative databases to identify 12,676 patients who underwent bariatric surgery between 2001 and 2014 as well as age- and sex-matched controls with obesity (n = 38,028) and controls without obesity (n = 126,760) to determine whether bariatric surgery increases the risk for fracture.
At least one fracture was present in 10.5% of the bariatric surgery group, 8.1% of the obesity group and 6.6% of controls without obesity before surgery. Compared with controls without obesity, the risk for fracture was significantly higher in the bariatric surgery group (RR = 1.3; 95% CI, 1.21-1.39) and controls with obesity (RR = 1.18; 95% CI, 1.13-1.23) after adjustment for comorbidities, fracture history, socioeconomic deprivation and area of residence.
The bariatric surgery group was more likely to have sustained at least one fracture (4.1%) after a mean follow-up of 4.4 years compared with 2.7% of controls with obesity and 2.4% of controls without obesity. The bariatric surgery group had a significantly higher postoperative adjusted fracture risk compared with controls without obesity (RR = 1.44; 95% CI, 1.29-1.59) and controls with obesity (RR = 1.38; 95% CI, 1.23-1.55).
Compared with controls without obesity, the bariatric surgery group and controls with obesity had a higher risk for distal lower limb fracture and a lower risk for upper limb fracture. Compared with controls without obesity, the bariatric surgery group had higher risks for upper limb (RR = 1.65; 95% CI, 1.42-1.91), clinical spine (RR = 1.7; 95% CI, 1.06-2.73) and pelvic, hip and femur fractures (RR = 1.88; 95% CI, 1.37-2.58).
“Fracture risk assessment should be part of postoperative bariatric care,” Gagnon told Endocrine Today. “To minimize the effect of bariatric surgery on bone, guidelines should be followed and the importance of adherence to supplements and physical activity should be reinforced among patients and health care professionals. A referral to a bone specialist should be considered in cases in which fracture risk is high before surgery or when the biochemical parameters do not normalize of a fracture occurs after surgery. Finally, it is important to weight the benefits and risks of surgery for a given patient in order to propose the type if surgery that is best suited to the patient, as the efficacy of bariatric surgeries differs in terms of resolution and comorbidities associated with obesity.”
In an accompanying editorial, Marco Bueter, MD, PhD, attending surgeon and head of the bariatric program at University Hospital Zurich in Switzerland, wrote that the study “contribute[s] to an important research area, exploring the long term effects of bariatric surgery.”
“On the basis of the data presented by Rousseau and colleagues, as a bariatric surgeon I will certainly consider including assessment of fracture risk in the interdisciplinary algorithm of post-bariatric care for all my patients in the future,” he wrote. – by Amber Cox
For more information:
Claudia Gagnon, PhD, FRCPC, can be reached at Claudia.gagnon@crchudequebec.ulaval.ca.
Disclosure: Gagnon reports financial ties with Amgen and Eli Lilly. Bueter reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
Back to Top
Matthew T. Drake
The weight loss associated with bariatric surgery can result in significant skeletal unloading, whereas the malabsorption that occurs as part of some procedural types, including biliopancreatic diversion and Roux-en-Y gastric bypass, can lead to significant nutritional deficiencies. Historically, neither changes in skeletal health nor nutritional deficits have been particularly well monitored by clinicians in the years following bariatric surgery, although both skeletal unloading and malabsorption can logically be expected to result in bone loss and increased fracture risk. In this vein, and as well-demonstrated in this study, is the authors’ observation that the pattern of fractures in patients undergoing bariatric surgery markedly changed in the years following surgery, with patients who underwent biliopancreatic diversion showing an increased risk for osteoporotic-type (upper limb, clinical spine, pelvic, hip, femur) fractures. Caveats to the study include the relatively limited number of subjects who underwent Roux-en-Y gastric bypass, and that subjects who underwent bariatric surgery were not well matched in all respects to obese control subjects who did not undergo bariatric surgery. As example, bariatric surgery-treated subjects had a significantly higher baseline rate of diabetes, which is a known risk factor for fractures, perhaps reflecting glycemic-associated impairments in bone quality. Nevertheless, the presented data strongly argue for careful ongoing assessment of skeletal health in all patients undergoing bariatric surgery, particularly following procedures with a malabsorptive component. While best approaches to limit fracture risk in such patients remain to be determined, they will be important to develop given the burgeoning practice of bariatric surgery.
Disclosure: Drake reports no relevant financial disclosures.
Click Here to Manage Email Alerts