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Exercise prevents bone loss after bariatric surgery
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Women with severe obesity who underwent Roux-en-Y gastric bypass surgery followed by a 6-month exercise program did not experience the bone loss observed in similar women who underwent gastric bypass followed by standard care, according to findings published in The Journal of Clinical Endocrinology & Metabolism.
“Exercise training is a relevant, simple, therapeutic tool to mitigate bone loss in obese patients undergoing bariatric surgery,” Bruno Gualano, PhD, an associate professor in exercise physiology with the School of Medicine of the University of Sao Paulo, told Endocrine Today. “It can enhance the metabolic benefits as well as protect bone mass when combined with the surgery.”
Gualano and colleagues analyzed data from 70 women with severe obesity (BMI 40 kg/m² or 35 kg/m² with comorbidities; seven women withdrew before surgery) aged 25 to 55 years, recruited through the bariatric and metabolic surgery unit of University of Sao Paulo Hospital. Before surgery, researchers randomly assigned women to Roux-en-Y gastric bypass plus exercise training initiated 3 months after surgery (n = 31; mean age, 40 years) or to bariatric surgery plus standard care (n = 32; mean age, 42 years). The exercise regimen consisted of a one-on-one, supervised program three times a week at the hospital for 6 months. Training sessions focused on strengthening exercises and aerobic exercise on a treadmill. All patients were reassessed at 9 months after surgery. Primary outcome was areal bone mineral density; secondary outcomes were bone microarchitecture, bone turnover and biochemical markers.
Researchers found that, when compared with women who received standard postsurgical care, exercise mitigated the percent loss of areal BMD at the femoral neck (estimated mean difference, –2.91; 95% CI, –0.85 to –4.98), total hip (estimated mean difference, –2.26; 95% CI, –0.58 to –3.93), distal radius (estimated mean difference, –1.87; 95% CI, –0.1 to –3.64), and cortical volumetric BMD at distal radius (estimated mean difference, –2.09; 95% CI, –0.29 to –3.9).
Researchers also found that exercise attenuated levels of C-terminal telopeptide of type 1 collagen (CTX; estimated mean difference, –0.2 ng/mL; 95% CI, –0.08 to –0.33), procollagen type 1 N-terminal propeptide (P1NP; estimated mean difference, –17.59 ng/mL; 95% CI, –2.35 to –32.83) and sclerostin levels (estimated mean difference, –610 pg/mL; 95% CI, –11 to –1,209), in comparison with standard care.
Exercise was not associated with changes in levels of serum vitamin D, calcium, parathyroid hormone, phosphorus or magnesium, according to researchers.
“Post-surgery exercise should be incorporated into the patient’s routine to attenuate bone loss, which is one of the most severe adverse effects related to the surgical procedure,” Gualano said.
Gualano added that it is important to understand how exercise protects bone in the postsurgical condition.
As Endocrine Today previous reported, older adults who undergo Roux-en-Y gastric bypass surgery are more likely to experience a nonvertebral fracture compared with those who undergo adjustable gastric banding. In a study published in JAMA Surgery in May, researchers found that, among a cohort of nearly 30,000 adults, those who had Roux-en-Y gastric bypass were 73% more likely to experience a fracture (HR = 1.73; 95% CI, 1.45-2.08) and were also more likely to have hip (HR = 2.81; 95% CI, 1.82-4.49), wrist (HR = 1.7; 95% CI, 1.33-2.14) and pelvis (HR = 1.48; 95% CI, 1.08-2.07) fractures compared with those who had adjustable gastric banding.
“Sclerostin emerges as a potential bone marker that could partially explain this effect, but experimental studies should validate this hypothesis,” Gualano said. “In addition, we don’t know yet whether exercise can prevent fractures in this population. Long-term trials involving exercise are necessary.” – by Regina Schaffer
For more information :
Bruno Gualano, PhD, can be reached at Universidade de Sao Paulo, SP, BR, Av. Dr. Arnaldo, 455 Pacaembu, Sao Paulo, Brazil 01246-903; email: gualano@usp.br.
Yu EW, et al. JAMA Surg. 2019; doi:10.1001/jamasurg.2019.1157.
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Sue Shapses, PhD, RD
Losing bone with weight loss is not good for anyone, and these findings demonstrating that bone loss is prevented with exercise in the bariatric patient is good news.
Attenuating bone loss with exercise during modest weight reduction has been shown by a few groups, but knowing bone loss can be attenuated with extreme weight loss after Roux-en-Y gastric bypass is important due to higher risk for fracture years after the procedure in this patient group. Severely obese persons have a higher BMD at all sites compared with persons of lower body weight. However, whereas people with severe obesity typically have higher bone density, the bone is often of poorer quality. This means that, for a given BMD level, their bone is at higher risk for fracture vs. people with lower body weight (and lower BMD).
This leads to other questions: Is the BMD gained good, quality bone, and can it be maintained beyond the short-term period of this study? This information will help us determine whether there are clinical benefits to ultimately prevent fracture risk in this vulnerable patient population.
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