Fracture Risk After Bariatric Surgery: A 12-Year Nationwide Cohort Study

Chia-Wen Lu, Yu-Kang Chang, Hao-Hsiang Chang, Chia-Sheng Kuo, Chi-Ting Huang, Chih-Cheng Hsu, Kuo-Chin Huang, Chia-Wen Lu, Yu-Kang Chang, Hao-Hsiang Chang, Chia-Sheng Kuo, Chi-Ting Huang, Chih-Cheng Hsu, Kuo-Chin Huang

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.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

FIGURE 1
FIGURE 1
Cumulative incidence of fracture in the patients receiving bariatric surgery and the matched controls.

References

    1. Flegal KM, Carroll MD, Kit BK, et al. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. J Am Med Assoc 2012; 307:491–497.
    1. Björntorp P. Obesity. Lancet 1997; 350:423–426.
    1. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013; 23:427–436.
    1. Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. J Am Med Assoc 2015; 313:62–70.
    1. Goldner WS, O’Dorisio TM, Dillon JS, et al. Severe metabolic bone disease as a long-term complication of obesity surgery. Obes Surg 2002; 12:685–692.
    1. von Mach MA, Stoeckli R, Bilz S, et al. Changes in bone mineral content after surgical treatment of morbid obesity. Metabolism 2004; 53:918–921.
    1. Coates PS, Fernstrom JD, Fernstrom MH, et al. Gastric bypass surgery for morbid obesity leads to an increase in bone turnover and a decrease in bone mass. J Clin Endocrinol Metab 2004; 89:1061–1065.
    1. Mahdy T, Atia S, Farid M, et al. Effect of Roux-en Y gastric bypass on bone metabolism in patients with morbid obesity: Mansoura experiences. Obes Surg 2008; 18:1526–1531.
    1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. J Am Med Assoc 2004; 292:1724–1737.
    1. Tsiftsis DD, Mylonas P, Mead N, et al. Bone mass decreases in morbidly obese women after long limb-biliopancreatic diversion and marked weight loss without secondary hyperparathyroidism. A physiological adaptation to weight loss? Obes Surg 2009; 19:1497–1503.
    1. Johnson JM, Maher JW, Samuel I, et al. Effects of gastric bypass procedures on bone mineral density, calcium, parathyroid hormone, and vitamin D. J Gastrointest Surg 2005; 9:1106–1110.
    1. Fleischer J, Stein EM, Bessler M, et al. The decline in hip bone density after gastric bypass surgery is associated with extent of weight loss. J Clin Endocrinol Metab 2008; 93:3735–3740.
    1. Marceau P, Biron S, Lebel S, et al. Does bone change after biliopancreatic diversion? J Gastrointest Surg 2002; 6:690–698.
    1. Strauss BJ, Marks SJ, Growcott JP, et al. Body composition changes following laparoscopic gastric banding for morbid obesity. Acta diabetologica 2003; 40:S266–S269.
    1. Pugnale N, Giusti V, Suter M, et al. Bone metabolism and risk of secondary hyperparathyroidism 12 months after gastric banding in obese pre-menopausal women. Int J Obes Relat Metab Disord 2003; 27:110–116.
    1. Vilarrasa N, Gomez JM, Elio I, et al. Evaluation of bone disease in morbidly obese women after gastric bypass and risk factors implicated in bone loss. Obes Surg 2009; 19:860–866.
    1. Vage V, Gjesdal CG, Eide GE, et al. Bone mineral density in females after jejunoileal bypass: a 25-year follow-up study. Obes Surg 2004; 14:305–312.
    1. Nakamura KM, Haglind EG, Clowes JA, et al. Fracture risk following bariatric surgery: a population-based study. Osteoporos Int 2014; 25:151–158.
    1. Lalmohamed A, de Vries F, Bazelier MT, et al. Risk of fracture after bariatric surgery in the United Kingdom: population based, retrospective cohort study. Br Med J 2012; 345:e5085.
    1. Cheng TM. Taiwan's new national health insurance program: genesis and experience so far. Health Affairs 2003; 22:61–76.
    1. D’Agostino RB., Jr Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 1998; 17:2265–2281.
    1. Iezzoni L. Risk Adjustment for Measuring Healthcare Outcomes. 2nd ed.Chicago, IL: Health Administration Press; 1997.
    1. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45:613–619.
    1. Carrasco F, Ruz M, Rojas P, et al. Changes in bone mineral density, body composition and adiponectin levels in morbidly obese patients after bariatric surgery. Obes Surg 2009; 19:41–46.
    1. Brzozowska MM, Sainsbury A, Eisman JA, et al. Bariatric surgery, bone loss, obesity and possible mechanisms. Obes Rev 2013; 14:52–67.
    1. Weitzmann MN, Pacifici R. Estrogen deficiency and bone loss: an inflammatory tale. J Clin Invest 2006; 116:1186–1194.
    1. Guney E, Kisakol G, Ozgen G, et al. Effect of weight loss on bone metabolism: comparison of vertical banded gastroplasty and medical intervention. Obes Surg 2003; 13:383–388.
    1. Oh KW, Lee WY, Rhee EJ, et al. The relationship between serum resistin, leptin, adiponectin, ghrelin levels and bone mineral density in middle-aged men. Clin Endocrinol 2005; 63:131–138.
    1. Steppan CM, Crawford DT, Chidsey-Frink KL, et al. Leptin is a potent stimulator of bone growth in ob/ob mice. Regul Pept 2000; 92:73–78.
    1. Hamrick MW, Della-Fera MA, Choi YH, et al. Leptin treatment induces loss of bone marrow adipocytes and increases bone formation in leptin-deficient ob/ob mice. J Bone Miner Res 2005; 20:994–1001.
    1. Edwards C, Hindle AK, Fu S, et al. Downregulation of leptin and resistin expression in blood following bariatric surgery. Surg Endosc 2011; 25:1962–1968.
    1. Luo XH, Guo LJ, Xie H, et al. Adiponectin stimulates RANKL and inhibits OPG expression in human osteoblasts through the MAPK signaling pathway. J Bone Miner Res 2006; 21:1648–1656.
    1. Folli F, Sabowitz BN, Schwesinger W, et al. Bariatric surgery and bone disease: from clinical perspective to molecular insights. Int J Obes 2012; 36:1373–1379.
    1. Scibora LM, Ikramuddin S, Buchwald H, et al. Examining the link between bariatric surgery, bone loss, and osteoporosis: a review of bone density studies. Obes Surg 2012; 22:654–667.
    1. Stein EM, Carrelli A, Young P, et al. Bariatric surgery results in cortical bone loss. J Clin Endocrinol Metab 2013; 98:541–549.
    1. Yu EW, Bouxsein ML, Putman MS, et al. Two-year changes in bone density after Roux-en-Y gastric bypass surgery. J Clin Endocrinol Metab 2015; 100:1452–1459.
    1. Dogan K, Aarts EO, Koehestanie P, et al. Optimization of vitamin suppletion after Roux-en-Y gastric bypass surgery can lower postoperative deficiencies: a randomized controlled trial. Medicine 2014; 93:e169.

Source: PubMed

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