title: Bone and mineral metabolism in patients undergoing Roux-en-Y gastric bypass.
abstract: Despite effective weight reduction, the impact of bariatric surgery on bone is a major concern. Mechanisms include decreased mechanical loading, calcium and vitamin D malabsorption, deficiency in other nutrients, and alterations in fat- and gut-derived hormones. The evidence to support clinical care pathways to prevent bone loss and fractures is at this point weak.
  
  
  BACKGROUND
  There is a growing concern regarding the potential deleterious impact of bariatric surgery on bone metabolism. This comprehensive review addresses this controversial topic.
  
  
  METHODS
  We reviewed and analyzed articles evaluating bone metabolism and mechanisms for the ensuing putative bone loss in adult patients exclusively undergoing Roux-en-Y gastric bypass (RYGB) surgery, for the period spanning 1942 till September 2012.
  
  
  RESULTS
  Mechanisms identified to contribute to alterations in bone metabolism after bypass surgery include: decreased mechanical loading, calcium and vitamin D malabsorption with secondary hyperparathyroidism, deficiency in other nutrients, in addition to alterations in adipokines, gonadal steroids, and gut-derived hormones favoring bone loss, with the exception of serotonin and glucagon-like peptide-1. The relative contribution of each of these hormones to changes in bone homeostasis after bypass surgery remains undefined. Bone loss reflected by a decline in bone mineral density (BMD) and an increase in bone turnover markers have been reported in many studies, limited for the most part by the exclusive use of dual energy X-ray absorptiometry. Well-designed long-term prospective trials with fractures as an outcome, and studies investigating the magnitude, reversibility, and impact of the observed metabolic changes on fracture outcomes are lacking.
  
  
  CONCLUSIONS
  Robust conclusions regarding bone loss and fracture outcome after RYGB surgery cannot be drawn at this time. Although not evidence based, baseline evaluation and sequential monitoring with measurement of BMD and calciotropic hormones seem appropriate, with adequate calcium and vitamin D replacement. Beneficial interventions remain unclear.
authors.affiliation: Department of Internal Medicine, Division of Endocrinology, Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut-Medical Center, PO BOX: 11-0236, Riad El Solh, 1107 2020, Beirut, Lebanon.
authors.forename: M P
authors.initials: MP
authors.lastname: Hage
authors.forename: G
authors.initials: G
authors.lastname: El-Hajj Fuleihan
mesh_terms: D015415:Biomarkers / Q000378:metabolism; D015519:Bone Density / Q000502:physiology; D001842:Bone and Bones / Q000378:metabolism*; D015390:Gastric Bypass / Q000009:adverse effects*; D006728:Hormones / Q000378:metabolism; D006801:Humans; D009765:Obesity / Q000601:surgery*; D010024:Osteoporosis / Q000209:etiology* / Q000378:metabolism / Q000503:physiopathology; D058866:Osteoporotic Fractures / Q000209:etiology
chemical_list: D015415:Biomarkers; D006728:Hormones