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Endocrine Feedback Loop
EFL067 - Bariatric Surgery and Changes in Body Composition and Musculoskeletal Health
00:43:01
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- [00:01]
A
This is endocrine feedback loop. I am your host Chase Hendrickson and welcome you to this Journal Club Podcast series brought to you by the Endocrine Society. Thanks for joining us as we explore an important article recently published in one of the Society's clinical journals. Welcome once again to the Endocrine Feedback Loop podcast for our 67th episode. Today we look at a study in the JCNM that reports the impact of different types of weight loss surgery on body composition, muscle strength and bone density. Our patients frequently ask these questions about these changes with surgical and medical weight loss, so we thought it highly worthwhile to review these findings with you all. This observational study is a secondary analysis of an RCT and we will think about the limitations that always come with these types of investigations. I host the Endocrine Feedback Loop and work at the Vanderbilt University Medical center in Nashville, Tennessee as a general endocrinologist and medical Director. Our regular contributor once again is Andrew Craftson from the University of Michigan in Ann Arbor. He focuses his clinical care and research on obesity, serving as a Director for the Weight Navigation Program and the Post Bariatric Endocrinology Clinic as well as an Assistant Director for the Weight Management Program at Michigan. Additionally, he is an expert educator working as an Associate Director for their Endocrinology Fellowship program. Our guest expert today comes to us from the University of California, San Francisco. Ann Schaefer is known to you all as an osteoporosis expert with numerous publications and talks in this area. Particularly exciting for us is that her specific area of expertise is the impact of obesity and weight loss on bone health, and much of her research focuses on understanding these relationships. As you can tell, the perfect pair of endocrinologists joins me today to discuss this topic. As always, everything we say will be our opinions only and not those of the Endocrine Society or of our respective institutions. For this month's episode, we review one year changes in body composition and musculoskeletal health following metabolic bariatric surgery, which the Journal of Clinical Endocrinology and metabolism published in May 2025. Friedrich Jassel from the University College London and Maria Papagiorgu from the University of Geneva served as first authors for this paper. I'll now turn things over to Andrew. He will walk us through the author's introduct and ask Ann to give us key insights along the way.
- [02:33]
B
Andrew, thanks for having me back Chase. Really great to be here and so great to have Dr. Shaffer here to provide her expertise. So I hope you both can Indulge me and our listeners can indulge me for a few seconds as I set the groundwork as we discuss this paper. As we all know with our patients, they have been subjected to decades long times of being just really told to do what society perpetuates in terms of myths and fad diets. But now, finally, in the more recent past, we've seen that our patients are being offered evidence based treatments to help for healthy weight control. As we all know, the GLP1 based therapies are really taking up all the oxygen in the room in terms of discussion and that's very understandable. They're exciting, they're effective. But we see that practice patterns are evolving and we wonder, are we focusing a little bit too much of our energy and time on these obesity modifying medications, also known as OMMs, and are we seeing a decline in the utilization of other treatment modalities? This is really important today as we talk because we have long known that metabolic bariatric surgery is really the most effective treatment for obesity and it provides the best chance of obesity remission, sustained maintenance of a reduced weight state and improvement of weight related health conditions. However, we all know that very few people actually get this surgery done and only 1 to 2% of eligible individuals actually end up pursuing surgery. We also know that in these recent times, the volume of cases of metabolic bariatric surgery seems to be on the decline with Some estimating that 25% reduction in volume is occurring. And this has been attributable to the use of OMMs. Now we really have to think about this because as insurers reduce, as they cap or stop coverage of these relatively expensive incretin treatments, patients and providers are remembering that metabolic bariatric surgery remains a steadfast and available tool. So even though we know that it's a very effective treatment, there are a lot of reasons that providers infrequently recommend it and patients rarely pursue it. You know, there are these misconceptions, there are knowledge gaps, there are cost concerns. We also know that people are worried about the perioperative, postoperative, long term surgical risks of this treatment. And really pertinent to today's discussion, we know that vitamin and nutrient absorption processing can be affected by surgery and that not all the body composition changes after surgery are positive. So let's bring Dr. Shaver into the conversation. So Ann, what can you tell us about the body composition changes that happen after bariatric surgery? And I know your bone is top of mind in your research and your thoughts yeah.
- [05:42]
C
Thank you so much. I'm really delighted to be here. Starting with big picture points, sort of the summary of what I think we'll be talking about today. Metabolic and bariatric surgery does result in early and pretty dramatic increases in bone turnover. It results in decreases in bone mass, bone mineral density, and also declines in bone microstructure. Now, some of those changes may be a physiologically appropriate adaptation to a person's new lower body weight, but we have reason to believe, we believe it's shown pretty clearly now that the changes exceed that and actually do become pathologic. We see that in the higher fracture risk that people have after undergoing bariatric surgery. Those are the big picture points. And I'm eager to go in depth more as we talk through things today.
- [06:39]
B
And we're excited to hear your expert thoughts on it too. So as we're trying to find what are the perfect treatments for obesity, of course they're not there yet, but we are trying to balance this effectiveness and the risks. And there's been a desire to address these concerns about surgery and its impact. And so surgery methods have evolved. We know that in 2012, the FDA approved laparoscopic sleeve gastrectomy as a standalone procedure. And since then, it really has skyrocketed in popularity. And it's really the most common metabolic bariatric surgery procedure performed in the US and probably worldwide. And there are a number of advantages, Right? So it has a relatively shorter operating time, it's more simple than other surgeries, and there's a lower degree of malabsorption. And so people do like the side effect and risk profile compared to some of the older or more aggressive surgeries. But I certainly see this in my clinic. We've seen that there is some sacrifice in terms of the potency of the surgery for weight and for reduction of weight related health conditions. And so some would say then that there are these aspects that are inferior to something like Roux en Y gastric bypass surgery. Now, people want to bridge this gap. How do we mitigate the side effects of Roux en y but also improve the efficacy of the surgery for weight? And so other procedures have been developed, such as the 1 anastomosis gastric bypass. In this procedure, a tubular gastric pouch is established that's a little bit different than the Roux en y. And the distal end is then connected to the jejunum 150-250 cm from the ligament of traits. It's got a longer pouch than is created in Roux en y. But it more extensively bypasses the jejunum. Notably, the two methods of the gastrointestinal reconstruction are different. So we do then want to know how is it in comparison to the Roux en y and also to the sleeve? And we know that it offers the advantage of a shorter operating time compared to Roux en Y, fewer early post operative complications, and it's actually easier of a technique to learn. However, there is limited long term data and limited information about the long term impact on vitamin and mineral deficiencies in the impact on bone health. They can impact the bones and it seems to increase bone fracture risk due to nutritional factors, mechanical unloading, hormonal factors and these changes in body composition and bone marrow fat. This seems to have a collective impact on the bone turnover, which you already alluded to mass microarchitecture. But if you kind of look through the the evidence, it can be confusing. There's a lot to sift through, unfortunately. You're such an expert and you can us with that. And so adding to this discussion that you already started, what is sort of that Reader's Digest version of the impact on the bone at the molecular level that could help our listeners?
- [09:56]
C
I'm going to answer bigger than the molecular level, at least at the beginning, just to explain what I think are the key points about research and the effects of bariatric surgery on a skeleton. As I said before, there is a very consistent, very well documented decrease in bone density after bariatric surgery, especially after the Roux en y gastric bypass and after the sleeve gastrectomy. I'll get to the comparisons in a moment. But some of the key take home points from the bulk of the literature, which is in the Roux en y gastric bypass. Roux en Y gastric bypass being the procedure that's been around longest and is very much the best studied in terms of skeletal effects. A few take home points. So one is the decrease in bone density has been very well documented not only by DEXA but also by qct. And why is that important? You know, one of the limitations of DEXA is, as you know, it can be frankly misleading or at least just biased in the setting of major changes in body composition. The way that it defines bone based on sort of the bone soft tissue interface, if that soft tissue is changing in its mass and also its composition, that can create some issues in terms of how well the bone is measured. It's been very important that the literature about the skeletal effects of bariatric surgery has also included qct, like volumetric Bone density of the spine and hips, volumetric bone density of ict, avoiding some of the pitfalls, the potential biases of the two dimensional dexa, we see it in multiple modalities. We also see loss of bone mass not only at weight bearing sites, but also at non weight bearing sites. Why is that important? So, as you mentioned, there are a whole bunch of different potential contributors to the loss of bone mass after bariatric surgery. A major one being the skeletal unloading. The mechanical aspects, you have less weight to carry around. And so via sclerostin pathways, for example, there's loss of bone potentially to kind of signal the bone that it doesn't need to carry around so much weight and it doesn't necessarily need to be as strong. So if it was just the weight bearing sites, that would be one thing and it would point to this mechanical unloading. But it's not just that. We also see, for example, when we use high resolution peripheral QCT to look at bone density and microstructure at the distal radius compared to the tibia, we see changes at the radius as well. So the non weight bearing bones effects there suggest that it is at least in part a systemic effect we've alluded to.
- [12:49]
B
There's limited Data about the 1 Anastomosis Gastric bypass procedure and much of the data, at least that I've seen really surrounds the perioperative risk period. And there's a paucity of data surrounding the impact of the procedure on vitamin nutrient status, body composition, bone health. So we alluded to that. However, the need to improve understanding is important because what was a bit surprising to me is that even though it's not approved in the US as a primary procedure, it's now the third most performed metabolic bariatric surgery worldwide. So understanding its impact is extremely important. And so that is where we get to the study. The aim of this study is to compare changes in body composition, bone mineral density, muscle strength and physical function in the first year following one anastomosis gastric bypass, Roux En Y and sleeve within a UK based healthcare setting. So I set the table. I know it took a while, but I'll hand it over to Chase to continue the discussion.
- [13:55]
A
Yes, thank you. This is an excellent start here and we're thinking about a lot of things that we've got to keep in mind and we're going to keep circling back to those as we move through the methods, results and discussion to get into the methods, we're going to first of all think about the study design that's used here. We'll get to it in a second. But this is a secondary analysis of an RCT and we want to be careful that whenever we see RCT we don't automatically assume, oh, this is the gold standard. This has no methodologic concerns that we have to keep in mind. This is an observational study and I think looking at this, I would characterize it as a retrospective cohort study. I think that's the best way to think about this as a reminder of how that study design works. With cohort studies, you have individuals who have different exposures, and in this case we have multiple different exposures. And that is how you decide, decide what lands you in one group and then what makes it a cohort study is that you follow those individuals over time. The exposure had to predate putting people into those groups. And then the outcomes that you're looking at those are developing over time and you're identifying those in relation to when the exposure happened. And that's what we have in mind here thinking about the overall study. So where this comes from. So this was a secondary analysis of the Berry lifestyle rct. So what this was, this was an RCT that was looking at the impact of an adjunct of life lifestyle program in individuals who are undergoing a metabolic bariatric surgery. Now the end result of that study is that it didn't make a difference. So that specific intervention, this, this lifestyle program didn't lead to greater weight loss. Whether you had it didn't have it didn't make a difference. So that's where these patients came from. So from that study, initially the inclusion criteria is you had to be an adult ages 18 to 65, you had to meet the standard eligibility criteria for bariatric surgery. And then you had to scheduled to undergo one of those three surgeries that we've mentioned already. Another part that was not mentioned specifically here, but I think we can infer from this, is that you had to have completed a bone density scan, a DEXA scan, both at baseline and then 12 months after surgery. Exclusion criteria, just a few is if because of the limitations of the bone density scan, the machine itself, the body weight could not be 200kg or more. And then some other criteria that were briefly mentioned that the patients could not be non ambulatory or have any functional limitations. So the numbers, the way this works, again, Initially that original RCT, they assessed over 500 individuals. Quite a few were excluded, so over 360 and that left 153 who were randomized. So then once you get down to the individuals who actually have the data that's available, there's 119. So just really briefly on those numbers. So a minority underwent the OAGB that one anastomosis, so that was only 16%. A third underwent the Roux En y gastric bypass with 39 individuals and then slightly over half had the sleeve gastrectomy. So now, Ann, we're going to get your input on this again, because the authors here describe the choice of surgery that it was based on informed patient preference. So just as an aside for our listeners, that's why we, when we're looking at this, we're not thinking of this as an rct. This was not a randomized decision. This is something that the patients and also the providers were deciding on. And help us understand what's the sort of thing that might make a patient, once they hear about this, decide one surgery versus another. And I'm going to add in that, as you're prepared to answer that question, I don't think it's entirely the patient decision here or else we would expect, I think, a far more even spread. There was clear center preference to which surgery they had there. So I think there was a pretty heavy influence here of providers and center preference. But just give us an overview. You've got three different surgical options. Why would somebody prefer one versus another?
- [17:47]
C
I think that the Roux En y gastric bypass has been demonstrated to have an especially profound effect on type 2 diabetes. And so at my institution, and I believe others, a person with diabetes might be more likely to either be encouraged towards or they've done their reading to look towards Roux En y gastric bypass for that reason. That's one possibility. Baseline weight. Similarly, at my institution, people with the most severe obesity are often encouraged towards Roux En y gastric bypass over sleeve gastrectomy just because even though the two have such very similar effects, positive effects on obesity and obesity related comorbidities, the Roux En y gastric bypass edges out the sleeve gastrectomy in many regards. And so that may be at play. And then conversely, you know, the other way of looking at those, I see people who are perhaps older, perhaps eager to have surgery, but maybe with slightly lower starting weights or fewer comorbidities, being more drawn towards sleeve because of its promise, or at least the hope that it might have fewer short and long term complications. Those are the main things that I.
- [19:11]
A
Pick out and the main reason that we discuss this is because all those extra things potentially serve as confounders whether that's something unique to the patient or unique to the center or the clinicians there. All things we have to keep in mind. The authors recognize that they do adjustments for those potential confounders. We'll talk about those here in a second. Before we get to that, we'll go through the outcomes just very briefly. Andrew will walk through them in more detail when we get to the results. But just to list them here. The first one is total body weight. Second one is body composition. So that includes visceral adipose tissue and BMD as measured by dexa. We're looking at the traditional sites for that total hip, femoral, neck and lumbar spine. We'll get to some of the caveats there. We've alluded to them already, but we'll talk about those in more detail later. We also looked at functional capacity using the six minute walk test. They looked at lower body functional capacity with a sit to stand test. There's also an assessment of static muscle strength that was with a hand grip test. There was an absolute and a relative way of assessing that. And those are the main outcomes that were looked at. So finally, as mentioned before the statistical analysis, the main point to highlight here is that they did adjust for a lot of these potential confounders. So they made adjustments for age, sex, menopausal status, height, weight, ethnicity, trial arm, the surgery site, smoking status, your supplement and HRT use, and finally your baseline bmd. Okay, with all of those things in mind, we're now going to go back to Andrew as we walk through the results as presented by the author.
- [20:44]
B
So thanks Chase. If you look at the paper, you'll see some of the specific numbers. I'll try to summarize them a bit, but we're looking at 119 participants included in the final analysis and the majority were women, 77% and almost 72% were premenopausal. The average age was about 46 and the average BMI was about 43. And we didn't see any significant differences at baseline between the groups in terms of body composition, bone mineral density or physical activity measures. There was a trend toward lower pre surgical use of anti diabetes medications in the sleeve gastrectomy group. One thing that I noticed is that there was a higher than average smoking rate compared to the US population and 55% of the participants were considered smokers. So Anne, what are some impressions you have about the baseline of these groups?
- [21:48]
C
Not in a way that I was not expecting. As you just said, the general population of people who undergo Metabolic and bariatric surgery are women. 80% women is the norm. That is what's seen in health system after health system. That was not surprising to me at all. Same with the average age. You know, 45, 46 is exactly what we expect. I too, was impressed that there were as many smokers as there were. But other things look very much like our patient populations here in the US and around my institutions.
- [22:26]
B
So when they looked at the metrics, the first thing they looked at was weight loss. And they actually didn't see a significant difference between these surgical types. So they lost, on average, approximately 25 to 27% total body weight loss at one year. And this was a little surprising to me. It's slightly different than some other studies that we've seen and slightly different than what we've seen in terms of Roux en Y versus sleeve gastrectomy. And I just make note of that here. Moving on to body composition, there was no significant differences between the surgical types. So there were significant decreases in fat mass percentage, lean body mass loss, body fat percentage loss, visceral adipose tissue and appendicular lean mass. So we'd see of the total fat mass, it was about 35 to 38% loss. Lean body mass, there was about 18 to 20% loss. Body fat percentage went down by 14 to 17. The visceral adipose tissue mass was a loss of 27 to 34%, and that appendicular lean mass was 17 to 22% loss. So that was a little bit less clear. I had to extrapolate from the figure. So none of that was extremely surprising in terms of what we would expect to see, the bone density, we see that there were reductions occurred at the sites and that the reductions were similar between 1 Anastomosis Gastric bypass and Roux en Y, but worse when compared to those of sleeve gastrectomy. So when they adjusted for those factors that Chase had talked about, they didn't necessarily see that there was this significance or the femoral neck between Roux en Y gastric bypass and sleeve or lumbar spine between one anastomosis gastric bypass versus sleeve. But when we look at the overall numbers, what we see is that what they saw at the total hip was negative 6.5% for the sleeve and about 9 to 10% for the other procedures. For the femoral neck, you'd see a 3% loss for sleeve and a 7 to 8% loss for the others. For the spine 2 versus 4.5%, we have this group that's 70 some percent premenopausal. And yet we're talking about these classifications of osteopenia and osteoporosis. And they're doing that by T scores. And so then they talk about, well, this number of people were in the osteopenia category before surgery, this many after. We had no individuals who were labeled as having osteoporosis before. Now we have one person. How significant is that with the classification, you know, low bone density for age, if you're premenopausal versus the osteopenia and osteoporosis? Am I just seeing a semantic.
- [25:37]
C
Yeah, no. I had the same thoughts too, because we want this to be clinically relevant and immediately transferable. I also wished that the authors had done that a little bit differently in order to be consistent with how we do things in clinical practice, which, as you know, is that we use T scores for postmenopausal women and men 50 and older for premenopausal women and men under 50. We don't diagnose osteoporosis based on T score. We say that a person has low bone mass for age. And the diagnosis of osteoporosis in a premenopausal woman or a man under 50 is something that we only very carefully make in a person with low bone mass per age and documented skeletal fruit fragility. So technically, I would have preferred the authors to split out the postmenopausal women from the premenopausal, the men over 50 from the men under 50, and then to report those things separately. And how many people had low bone mass for age would have been a nice thing that they could have reported that way. I want to get to one key point of interpretation, as you all described, and I'll just state again for the listener, the average 12 month percentage declines in bone density that were seen in the Roux En Y gastric bypass and the 1 anastomosis gastric bypass were on the order of like 6 to 8% declines at the femoral neck and like 9 to 10% declines at the total hip and then at the lumbar spine, 4 1/2% declines after sleeve gastrectomy. The mean decreases were 3.3% of the femoral neck, 6.5% of the total hip and 2% at the lumbar spine. So it may very well be that the declines are smaller at the lumbar spine than at the femoral neck or total hip. But this is where I think it becomes relevant and important to Remember that this is dexa, that we're using DEXA, which has that potential bias in the setting of marked soft tissue change. Because in studies that my group has done and other groups, including for example the group of Elaine Yu at Massachusetts General Hospital, when we have used DEXA but also have had people undergo QCT scanning to look at volumetric bone density, we actually see decreases in lumbar spine volumetric bone density by QCT that are on par with the DEXA decreases. So the lumbar spine bone density decreases go along with the hip decreases in magnitude. And so I think that there's a good likelihood, likelihood that what appear to be lesser smaller effects at the lumbar spine in this study, particularly in the sleeve gastrectomy group, that might be an imaging artifact issue and that if they had used a QCT approach, they might have seen larger effects.
- [28:47]
B
The final results that they report have to do with muscle strength and physical function. And they were looking at changes from baseline. And what they saw was that the absolute hand grip strength based on that, that meter that they used decreased by 6.5 to 9.5%. But when they adjusted for weight, they actually showed an increase in relative muscle strength of 16 to 27% increase in that they found that the sitting to stand test that people decreased the time, so that was better by about 25, 27% and that the six minute walking test that showed the that there was an improved duration of what they could do in that time limit by anywhere from 34 to 38%.
- [29:37]
C
Yeah, I was interested to see this because we have seen this in our participants after gastric bypass and after sleeve gastrectomy as well. And I think it's a noteworthy phenomenon. After metabolic and bariatric surgery, lean mass decreases. Lean mass measured by DEXA in absolute terms, strength decreases here measured by grip strength, meaning like the force that a person can apply decreases after bariatric surgery. But if you take into account their body mass and the very large decreases, and if you calculate what our like geriatrics colleagues and our sarcopenia expert colleagues often calculate in terms of muscle quality measures of strength divided by apple perpendicular lean mass or strength divided by total mass or bmi. If you do that, you find that that ratio that relative strength actually increases. So the absolute decrease in grip strength is smaller relative to the very large changes in body mass or muscle mass. What that means, tough to say, but it means that, that we shouldn't be too quick to say that a person loses strength and we shouldn't be too quick to conclude that they are worse off for it. And to that point, when these physical performance measures are collected or performed, we see that people generally improve after bariatric surgery. Gait speed increases in other studies and here that sit to stand time improves. 6 meter walk time improves. And that is great. I mean you can think about this in so many different ways. I mean people who had been severely obese may have had just a hard time maneuvering around in their environment and now they can move. People who used to have joint pain may have improvements in those joint pain. People may have the ability to exercise more and now they are more cardiovascularly fit. There are a lot of different potential reasons but but people seem to be better off when it comes to physical function, physical performance postoperatively.
- [32:00]
A
Now we will move on to the discussion points and we'll start with how the author summarized their work. And I would say that they identified three main findings at the very beginning, so I'll quote them here. The first one that the author state in referring to metabolic bariatric surgery is that it resulted in loss of lean mass with no difference between types of surgery. The second finding is that improvements in relative hand grip strength and physical function were observed after all types of surgery with no significant differences between surgical types. And then finally one anastomosis, gastric bypass and Roux En y gastric bypass resulted in more pronounced decreases in bone mineral density compared with sleeve gastrectomy. The authors then go on to compare their work to other published studies and they say that the findings on body composition largely aligned with these other studies, though they did find some differences related to bnd. And I want to get you some input from you on this because the authors then after that they go on to propose a few mechanisms. They outline some of the potential ways that these different surgeries could lead to this BMD loss. Importantly, they then go on afterwards to speculate that they think probably the key ones are ones that are unrelated to weight loss because there wasn't a difference between the surgery types. So what are your thoughts on the speculations that the authors lay out for us in their discussion?
- [33:24]
C
I liked their discussion very much. I thought they did a nice job reviewing the potential underlying mechanisms. I think it goes without saying that there's a lot that changes after metabolic and bariatric surgery. And so it's a given that these things are going to be multifactorial, but we can think through what those are. The potential mechanisms include to some extent that mechanical unloading of the skeleton. And that's something where nowadays we understand the paracrine factors and the molecular level way better than we did, you know, 15, 20 years ago. But also changes in the nutritional aspects, including calcium and vitamin D, also protein, whether a person's getting enough there changes in fat secreted hormones, adipokines may be at play, changes in sex hormones, as there's less fat mass and less aromatization of androgens to estrogens, for example, that may affect things and then other aspects that have been explored in the literature and we could go on and on about but things that include changes in bone marrow adiposity, changes in gut secreted hormones, whether incretins have an effect, changes in the gut microbiome. We see evidence that people who have more changes in gut microbiome composition may have worse changes in bone. So there's a lot there. I think that it's tough to conclude that they have to be unrelated to or that there's a predominance of a weight loss. It's tough to conclude that just because they are so very interdependent. For example, in one of our studies of calcium absorption, we did actually find that those who lost the most weight had declines in fractional calcium absorption and that that might have been related to the surgical procedure itself, like a longer Roux limb, for example, causing worse calcium absorption and also more malabsorption of other things leading to more weight loss. But there could also be other explanations. So tough to really like separate out these factors. But there's definitely more going on than just the number of pounds. Definitely more going on.
- [35:48]
A
As an obligatory aside from the authors, they've mentioned that the effects of GLP1 receptor antagonism on lean mass and BMD remain unclear. They then go on to talk about some of the limitations. We've mentioned some of these already, but they do point out that they had unequal sample sizes between the different types of surgery. They do acknowledge that this is a secondary data analysis and as a part of this easily underpowered and that it was not randomized. They also acknowledged that women were the majority of their subjects and that about half of them did receive that adjunctive lifestyle intervention program, though the results so that study showed that that program didn't make a difference. And then finally, something we've not talked about, they do acknowledge that they don't have any data on bone related markers. The authors then go on in their conclusion to give a summary and then what I describe as an implication. So they state in summary that metabolic bariatric surgery produced substantial weight loss alongside improvements in body composition, relative muscle strength and physical function, accompanied by loss of lean mass, upper body muscle strength and BMD with 1 and astomosis Gastric bypass and Roux en Y gastric bypass associated with more pronounced reductions in BMD at clinically relevant sites compared to sleeve gastrectomy. In that implication, the authors state that these results have implications for BMD monitoring and patients management. They'll comment that they didn't actually state what those implications are, they left them as implied. But we will move on to think about our own practice and whether that should change. First of all though, let's just think about the study overall, the quality of it. Andrew, let's start with you as you work through this. What was your impression about the quality of this report as a whole?
- [37:34]
B
I thought the quality was good. I like the emphasis on not just imaging characteristics but also the physical function piece of things. I think these are important clinical parameters for us to be thinking about, especially as we get beyond just looking at weight and BMI and thinking about how does whole body health change and this will be important for our patients as they consider different treatment modalities.
- [37:59]
A
Ann, same question for you. Thoughts on the quality of this report overall.
- [38:02]
C
I agree. I think the authors did a really thoughtful job taking data from this retrospective cohort study and accounting for potential confounding factors, namely the fact that the three different hospitals each predominantly did a different procedure and that there are practice differences. But they took that into account, they did their best. And I think what results are some really interesting and useful data.
- [38:29]
A
So let's stay with the usefulness of that data, certainly as it applies to clinical practice. So Andrew, back to you thoughts on this. So as you look at this data, you see many, many patients who are wrestling with this question, trying to decide which surgery they should have, if they should have surgery or on the back end of that, you're monitoring folks who have had surgery already and trying to decide what they need to have done about their bones, how that's going to be monitored, how that's going to be treated. Do you see yourself changing your clinical practice or would you advocate that we should our clinical practices as a whole based on the results of this study?
- [39:02]
B
Well, what I would hope is that all of us don't just look at age, that we think about what is the physiologic effect of these surgeries and that we really try to emphasize to these patients some of these talking points. You know, that you don't absorb as much calcium as you used to that you don't have as much food so you're absorbing less of less, and that there are reasons why these recommendations are in place for supplementation and try to build the rationale for that to also think about the long, long term. We're not just following a number on a scale that we're thinking about this longitudinal health and that includes bone health. And so I'd like to see that we can improve our screening methodologies. We do have dexa, but for many of our patients, we can't get it covered if they're younger. And so thinking about what are the policies that should be in place for those who've had metabolic bariatric surgery, I would like to see some reinvestigation about that and that we bring this up at each and every time to say just because the calcium level is fine doesn't mean you don't need the calcium or doesn't mean that you should stop the calcium and that there are real reasons why we're doing that, but also that encouragement of the function aspect of things that we can not just be scared about losing muscle, that you will potentially have better quality of life and better function, functional life.
- [40:23]
A
Andrew approaches this from a obesity medicine perspective. And you've got a slightly different angle on this, really focused on the bones here. So same question for you though, with this different perspective, thoughts on whether this should change our practice as a whole?
- [40:37]
C
You know, my perspective's very similar to Andrew's. I agree. This is, I think, a reminder to us all to think about a person's whole body, to think about musculoskeletal health during the weight loss process. Process. First, I will say I appreciated this because it contributes pretty meaningfully to the scant literature that exists right now about the 1anastomosis gastric bypass. My institution is not offering 1anastomosis gastric Bypass at this time, but we may in the future. And I hope that we'll have data in advance of that so that we're not going into things blind. But for the people who undergo surgery now, I agree. I mean, we need to remember that the potential benefit from these operations can be huge and we need to think about a person's whole body. We need to make sure that primary providers and endocrinologists and surgeons are all on the same page giving evidence based advice about nutrition, about evaluation of bone health and following a person along so that we can make sure that we're doing everything we can to maintain bone health as much as possible during the weight loss process. I think this paper gives us some great additional information and confirms that it's something that needs to be on our agenda.
- [42:03]
A
And with that, I would like to thank Andrew Craftson and Ann Schaefer for joining me for this month's edition of Endocrine Feedback Loop. I learned a lot and know that you all did as well. Please join us again next month. And now you're in the loop. This has been Endocrine Feedback Loop. Endocrine Feedback Loop is brought to you by the Endocrine Society with Production oversight by Brandy Brown and Andrew Harmon. If you want to like and subscribe, you can find us on Apple, Spotify, or wherever you get your podcast. We'd love to hear your feedback on this episode or the podcast itself. Please email us@podcastron.org. Endocrine Feedback Loop is a free service of the Endocrine System Society. To learn more or to become a member, visit the society's website at www.endocrine.org.