Can this really be?

Discussion in 'Duodenal Switch' started by Marquis Mark, Aug 6, 2018.

  1.  
    Marquis Mark

    Marquis Mark Well-Known Member

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    Just go my Dexa scan numbers back:

    2016: hip -1.5.
    2018 hip -2.2.
    That's a 47% decrease.


    2018: lumbar -.03.
    2018 lumbar -1.2.
    That's a 300% decrease.

    I'm a 54 year old male, non-smoker, non-drinker, with no family history of osteoporosis who walks a lot. At this rate, my bones will be balsa wood in a few years.

    My PTH is borderline high (60-70 usually) but normally not off the charts.

    What's going on?! Between this and my copper deficiency which isn't responding to 50 mg oral a day AND multiple sets of infusions I feel like I'm falling apart...
     
  2.  
    southernlady

    southernlady Administrator Staff Member

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    What was your last D lab value? Start by getting your PTH down. Keep it as close to the bottom end of normal as possible.
     
  3.  
    Marquis Mark

    Marquis Mark Well-Known Member

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    My D goes from between 40-80 despite taking 200K/day and getting an occasional D injection. My last calcium was 9.4. My last PTH was 61. Don't know what else I can do to bring the PTH down, but, from what I've read on this board it seems that even people with great PTH's have gotten osteo.

    My main concern is the SPEED of the decline. If it continues falling at this pace I'll have full blown osteo is 2 years.
     
  4.  
    southernlady

    southernlady Administrator Staff Member

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    Only took me 4 to get there despite great numbers. Some of us are just destined to have it, I suspect.
     
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    Marquis Mark

    Marquis Mark Well-Known Member

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    Was it the 4 years after you had the DS?
     
  6.  
    Spiky Bugger

    Spiky Bugger Well-Known Member

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    Mine was NOT in the first four years. But when it hit, it hit hard and fast.

    So, my spinal laminectomy surgery is on Sept. 5th. Until then, I stay loaded....and/or in horrid pain.

    I know you know this, but...
    1--there may be ZERO connection between YOUR DS and osteoporosis.
    2--I'm pretty much following my mother's "Compression Fracture/Spinal Stenosis Flow Chart." And she never had bariatric surgery.
    3--I once read that DexaScan results are based on a comparison to the scores of the average 26-year-old, so unless we find a way to make time stand still, the difference will likely increase each year.
     
    southernlady likes this.
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    southernlady

    southernlady Administrator Staff Member

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    Yeah, cause my first DEXA scan just after was fine, second was opteopenia, now osteoporosis.
     
  8.  
    DianaCox

    DianaCox Bad Cop

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    OK, before you freak out entirely:

    1) Your bones were abnormally dense before surgery, because your body added calcium to them to stand up to your excess weight. But note that both of your original numbers were already negative - AS COMPARED TO MEN HALF YOUR AGE. Those numbers were likely reasonably age-appropriate (not sure about that).
    2) As you lost weight, your body compensated by decreasing the calcium in your bones which was no longer needed - your body is SUPPOSED to do that.
    3) That decrease is measured in the DEXA scan as a value of "before and after" since the previous DEXA - it is NOT a mathematical representation of the actual AMOUNT of calcium in your bones, but rather as compared to normal young healthy men, between the two dates, so your calculation of "percentage decline" is not an actual number having any real-world meaning.
    4) You WILL lose bone over time, because that's what happens as we age.
    5) The way to prevent it from deteriorating any faster than it will anyway is to make sure you're getting enough vitamin D, calcium, magnesium, perhaps a few other things (boron? selenium? I'm not sure) and Vit K2 to ensure that the calcium transport system is working properly, and weight-bearing exercise.
    6) Your serum calcium levels mean nothing, so long as they are in the normal range - that range is tightly regulated, because your muscles (including heart muscle) and nerves require the levels to be in a specific range - your body will do everything and anything to keep it in that range. The only time you'll see those numbers off is SERIOUS malnutrition/hypercalcemia of late stage cancer (maybe a few other things), so you can be in trouble nutritionally and still be OK with your serum calcium as your bones and teeth are being depleted to Swiss cheese - but so long as there is something to steal calcium from, your blood levels will look good.

    It takes a while for the bones to catch up to the weight loss. You're only about 2.6 years out - I would not be unduly alarmed. But maybe add Vit K2 and some of the other bone minerals in case you're not absorbing them in sufficient quantities. Try to get your PTH down.
     
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  9.  
    Marquis Mark

    Marquis Mark Well-Known Member

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    Thank you, Diane et all.

    I'm going to try the vitamins and weightlifting and ask for another Dexa in a year. If it's still going south at the same rate I'll see about Reclast infusions (which seem to be the best for DS patients, no?)

    I get the part about less weight means less bone density, but, again, it's about THIS much less bone density THIS fast.

    I looked up some info:

    At age 30 we hit our peak bone density. It's all downhill from there, but the average man my age has a reading of 0. No, my numbers are not age appropriate unless I were a 175 year old man. I'm 54. In fact, most white males never even reach osteopenia:

    https://weinsteinimaging.com/userfiles/OSTEOPOROSIS Continued.pdf

    I knew the risks of DS. Just didn't think it would hit so hard and so fast. The benefits of DS (great BP, blood sugar, low cholesterol, not feeling humiliated, etc) are wonderful AND the side effects sometimes are scary. This is an AND story, not and either/or story.

    Interesting article below. It's about RNY, but I think there's a reasonable probability it applies to us. It certainly explains why a lot of us have great PTH, etc and still get osteo. They theorize it has to do with hormonal changes that are directly disturbing bone homeostasis.



    Gastric-Bypass Bone Loss Continues 5 Years Out
    Nancy A Melville

    September 18, 2017

    • American Society for Bone and Mineral Research (ASBMR) 2017 Annual Meeting, in presenting the findings here.

      While gastric-bypass surgery is associated with a host of important metabolic improvements, the surgery is also known to be linked to bone loss.

      Previous research from Dr Yu's team has shown Roux-en-Y gastric bypass to be associated with bone-density declines of 7% to 10% in the initial 2 years following bypass surgery and as much as a 40% to 50% increased risk of hip and wrist fractures.


      Research is lacking, however, on the longer-term trajectory of bone loss after weight loss stabilizes, which typically occurs within 2 years of gastric-bypass surgery.

      In commenting on the study, Anne Schafer, MD, an assistant professor of medicine and epidemiology and biostatistics at the University of California, San Francisco, said the research offers important new insights.

      "The 5-year data are very important for the characterization of the skeletal effects of gastric-bypass surgery," she told Medscape Medical News.

      The new study adds to the understanding of what those mechanisms may be, she said.

      "The findings of continued BMD decreases and detrimental changes in bone microstructure, even after weight stabilizes, suggest that there is indeed a cause for concern."

      Trial Findings
      To better understand the changes, Dr Yu and colleagues conducted a longitudinal study involving 21 Roux-en-Y gastric-bypass (RYGB) patients, including 17 female and four male patients, with bone measures available for up to 5 years after their gastric-bypass surgery.

      The patients, who had a mean age of 51, had a mean baseline body mass index (BMI) of 45 kg/m2 and after 5 years, the mean weight loss was 33 kg, with the weight stabilizing in all patients after 2 years and remaining stable until year 5.


      The patients maintained normal calcium, vitamin D, and parathyroid (PTH) levels in the first 2 years with supplementation, in which they essentially double their calcium intake and triple their vitamin D intake to compensate for reduced absorption related to the bypass surgery.


      Bone-mineral density (BMD) assessments of the patients at 5 years postsurgery using dual-energy x-ray absorptiometry (DXA) showed significant cumulative bone loss compared with levels at 2 years: total hip areal BMD decreased by 12% at 2 years and further to 15% at 5 years, compared with baseline, while femoral neck BMD dropped by 11% at 2 years, reaching 14% by 5 years (both P < .05 compared with 2 years).


      In the spine, areal BMD declines were 6% at 2 years and 8% at 5 years.

    • In assessments using quantitative computed tomography (QCT), the most significant bone loss was seen in the trabecular spine and hip: declining from 8% to 12% from 2 to 5 years in the trabecular spine and from 9% to as much as 20% in the trabecular hip (both P < .05 for both compared with 2 years).


      Assessments using high-resolution peripheral QCT (HR-pQCT), also showed significant declines from 2 to 5 years postsurgery in both trabecular and cortical bone.


      "Large cumulative declines in BMD and microarchitecture occur after RYGB, with continued worsening between years 2 and 5 at multiple skeletal sites and in both cortical and trabecular bone," the researchers conclude.


      "This persistent deterioration raises concerns about the long-term skeletal consequences of RYGB and indicates that active management of bone health in these patients is warranted."


      Serum CTX, a marker of bone resorption, increased by as much as 196% at 2 years and declined slightly at 5 years, but remained high at 150%, compared with baseline.


      Importantly, no correlations were found between changes in any of the BMD assessments and changes in weight, lean mass, or parathyroid (PTH) levels.


      Calcium? Hormones? Mechanisms Pondered
      Dr Yu said she is aware of only one other published study reporting on 5-year longitudinal bone-density changes after gastric bypass, a study published last year (Obes Surg. 2016;26:1141–1145).


      While the DXA-reported bone loss in that study was even greater (20%–25%), Dr Yu noted that patients in that study had minimal supplementation with calcium or vitamin D, whereas the current standard of care is to provide supplements to all patients after bypass.


      "It's difficult to know whether the significant calcium/D deficiency in that study may have contributed to the more severe skeletal outcome than seen in our study," she told Medscape Medical News.


      In terms of mechanisms, she said the lack of a correlation between bone loss and weight loss or changes in lean mass suggests that something other than skeletal unloading may contribute to the bone loss seen after gastric bypass.


      "When a person loses weight, some decline in BMD may be a natural, physiologically appropriate adaptation, as the skeleton has less body mass to support. However, recent studies documenting increased fracture risk after gastric bypass have indicated that there may be something more —something pathologic — happening in this patient population."


      "Calcium/vitamin D malabsorption may contribute, but I don't think it's the primary mechanism, since the most rapid bone loss occurs within the first 2 years, a time period where our patients were aggressively supplemented with calcium/D and maintained normal PTH levels without secondary hyperparathyroidism.


      "I believe that there are likely hormonal changes that are directly disturbing bone homeostasis," she explained.


      For example, gastric-bypass surgery induces changes in gastrointestinal hormones, including GLP-1 and PYY, and adipocytic hormones, including leptin and adiponectin, as well as changes in the gut microbiome, Dr Yu said.


      "Many of these factors have also been found to have a direct effect on bone.


      "It's possible that the same factors that are helping patients to lose weight and put diabetes in remission may also have the unintended consequence of causing bone loss."


      Clinical Implications: Keep Up Supplementation Post-RYGB and More Research


      While a proven intervention to prevent the bone loss associated with gastric-bypass surgery remains elusive, emerging evidence points to some key potential strategies to help minimize the effects, Dr Yu noted.


      For example, "it's clear that poor adherence with calcium and vitamin D supplements leads to even worse bone loss," she said.


      "Also, one or two studies have found that exercise interventions may mitigate (but not eliminate) the magnitude of RYGB-induced bone loss; this needs to be confirmed in larger and longer studies.


      "Finally, high-risk patients, such as older patients, those with history of fractures, or those that start with lower bone density, might additionally need pharmacologic medications to prevent bone loss after surgery, but we don't yet have clinical trials to demonstrate the efficacy or safety of such treatments."


      Dr Yu and Dr Schafer had relevant financial relationships.


      American Society for Bone and Mineral Research 2017 Annual Meeting. September 11, 2017, Denver, Colorado. Abstract 1125.
     
    Last edited: Aug 7, 2018

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