Abstract
Given the complex relationship between body mass index, body composition, and bone density and the correlative nature of the studies that have established the prevailing notion that higher body mass indices may be protective against osteopenia and osteoporosis and, therefore, fracture, the absolute risk of fracture in patients with severe obesity who undergo either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) compared with those who do not undergo bariatric surgery is unknown. To assess the rates of fractures associated with obesity and compare rates between those who do not undergo bariatric surgery, those who undergo RYGB, and those who undergo SG. In this retrospective multicenter cohort study of Medicare Standard Analytic Files derived from Medicare parts A and B records from January 2004 to December 2014, patients classified as eligible for bariatric surgery using the US Centers of Medicare & Medicaid criteria who either did not undergo bariatric surgery or underwent RYGB or SG were exactly matched in a 1:1 fashion based on their age, sex, Elixhauser Comorbidity Index, hypertension, smoking status, nonalcoholic fatty liver disease, hyperlipidemia, type 2 diabetes, osteoporosis, osteoarthritis, and obstructive sleep apnea status. Data were analyzed from November to December 2019. RYGB or SG. The primary outcome measured in this study was the odds of fracture overall based on exposure to bariatric surgery. Secondary outcomes included the odds of type of fracture (humerus, radius or ulna, pelvis, hip, vertebrae, and total fractures) based on exposure to bariatric surgery. A total of 49 113 patients were included and were equally made up of 16 371 bariatric surgery-eligible patients who did not undergo weight loss surgery, 16 371 patients who had undergone RYGB, and 16 371 patients who had undergone SG. Each group consisted of an equal number of 4109 men (25.1%) and 12 262 women (74.9%) and had an equal distribution of ages, with 11 780 patients (72.0%) 64 years or younger, 4230 (25.8%) aged 65 to 69 years, 346 (2.1%) aged 70 to 74 years, and 15 (0.1%) aged 75 to 79 years. Patients undergoing RYGB were found to have no significant difference in odds of fractures compared with bariatric surgery-eligible patients who did not undergo surgery. Patients undergoing undergone SG were found to have decreased odds of fractures of the humerus (odds ratio [OR], 0.57; 95% CI, 0.45-0.73), radius or ulna (OR, 0.38; 95% CI, 0.25-0.58), hip (OR, 0.49; 95% CI, 0.33-0.74), pelvis (OR, 0.34; 95% CI, 0.18-0.64), vertebrae (OR, 0.60; 95% CI, 0.48-0.74), or fractures in general (OR, 0.53; 95% CI, 0.46-0.62). Compared with patients undergoing SG, patients undergoing RYGB had a significantly greater risk of total fractures (OR, 1.79; 95% CI, 1.55-2.06) and humeral fractures (OR, 1.60; 95% CI, 1.24-2.07). In this cohort study, bariatric surgery was associated with a reduced risk of fracture in bariatric surgery-eligible patients. Sleeve gastrectomy might be the best option for weight loss in patients in which fractures could be a concern, as RYGB may be associated with an increased fracture risk compared with SG.
Highlights
Sleeve gastrectomy might be the best option for weight loss in patients in which fractures could be a concern, as Roux-en-Y gastric bypass (RYGB) may be associated with an increased fracture risk compared with sleeve gastrectomy (SG)
Given the complex relationship between body composition, bone density, and bone fragility as well as the correlative nature of the studies that have established the prevailing notion that higher BMIs may be protective against osteopenia, osteoporosis, and, fracture, here we explored the absolute risk of fracture in patients with severe obesity who did not undergo bariatric surgery, those who underwent surgical interventions with both restrictive and malabsorptive features (RYGB), and those who underwent surgical interventions with less malabsorptive features
The matched population analyzed in this study contained 49 113 patients, which were represented by 16 371 bariatric surgery–eligible patients who did not undergo weight loss surgery, 16 371 patients who underwent RYGB, and 16 371 patients who underwent SG
Summary
Bariatric surgery has increasingly become common as obesity has become a widespread concern in much of the high-income world.[1,2,3,4,5] These interventions have been shown to be associated with lasting and substantial weight loss, correction and protection from obesity-related conditions, and substantial benefits in quality of life and longevity.[2,3,6,7,8,9,10,11] Among obesity-related conditions, bariatric surgery has been demonstrated to reduce the burden of metabolic and cardiovascular diseases, migraines, and obesity-related risk of some cancers.[8,12,13,14,15,16,17,18] There is a large body of literature reporting an observational association between higher body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) and higher bone mineral density (BMD) that has implied that high BMI has protective effects on the skeleton and has led to the inference that loss of excessive body weight may result in decreases in BMD.[11,19,20,21,22] To this end, bariatric surgery might result in a decreased BMD and serve as a contributor to potentially higher rates and risks of fracture. Surgical weight loss approaches that alter the fundamental patterns of alimentary absorption, like Roux-en-Y gastric bypass (RYGB), may serve to hasten this risk and have been associated with the development of metabolic bone disease, resulting in higher bone turnover and long-term declines, disruptions, and deterioration in bone density and bone microarchitecture.[22,23,24,25,26,27,28,29,30]
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