Introduction
Materials and Methods
Selection Criteria
Bariatric Surgery Studies
Lifestyle Weight Management Programs
Outcomes
Search Strategy
Data Analysis
Results
Quality Assessment
Bariatric Surgery Trials
Lifestyle Intervention Studies
Study Characteristics
Bariatric Surgery Trials
Author year location | Number | Intervention | Diet; calories kcal/day | Exercise minutes per/week + intensity | % drop-out at the end of study | Follow-up months | Comorbidities/medications | Age (years) mean (SD) | % female | % ethnicity | BMI kg/m2 mean (SD) | Weight change (kg) (SD) | Fractures | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Courcoulas et al. 2014 Pittsburgh, USA [9] | Control | 23 | Lifestyle weight loss intervention | 1200–1800 Based on meal plans | 300 min of moderate physical activity | 26.1 | 12 | Type 2 diabetes Hypertension | 48.3 (4.7) | 82.6 | Black = 17.4 | 35.7 (3.3) | − 10.3 (11.8) | 0 |
Intervention | 46 | Roux-en-Y gastric bypass surgery Laparoscopic adjustable gastric banding | NR | Exercise a min of 3–4 times per week and to focus on weight-bearing, aerobic activity | 17.4 | 12 | 46.8 (7.0) | 80.5 | Black = 23.5 | 35.5 (3.0) | − 22.2 (10.3) | 1 | ||
Daumit et al. 2013 Baltimore, USA [16] | Control | 147 | Group health classes quarterly with topics not related to weight | NR | – | 3.4 | 18 | Schizophrenia Schizo-affective disorder Bipolar disorder Major depression | 44.1 (11.0) | 49.0 | White = 81.0 Black = 59.0 Other = 7.0 | 36.5 (7.3) | − 0.2 (9.1) | 4 |
Intervention | 144 | Group and individual weight loss counseling and group physical activity classes | Moderate caloric restriction based on DASH diet | ≥ 150 min/week of moderate physical activity | 4.9 | 18 | 46.6 (11.5) | 51.4 | White = 82.0 Black = 52.0 Other = 10.0 | 36.0 (7.2) | − 3.4 (7.8) | 2 | ||
Ditschuneit et al. 1999 Ulm, Germany [18] | Control | 50 | Conventional foods | 1200–1500 Balanced diet | – | 38.0 | 27 | Absence of endocrine or psychiatric disease | 46.6 (11.2) | 82.0 | – | 33.8 (3.2) | − 5.9 (5) | 1 |
Intervention | 50 | 2 meal replacements | 1200–1500 | – | 36.0 | 27 | 44.8 (9.7) | 76.0 | – | 32.4 (4.2) | − 11.3 (6.8) | 1 | ||
Hofso et al. 2010 Tonsberg, Norway [11] | Control | 66 | Lifestyle modification | NR | – | 4.5 | 12 | Type 2 diabetes Hypertension Metabolic syndrome Albuminuria Left ventricular hypertrophy Coronary heart disease | 47.0 (11.0) | 66.7 | White = 92.4 | 43.3 (5.0) | − 10.7 (12.0) | 1 |
Intervention | 80 | Roux-en-Y gastric bypass surgery | 788–908 3–6 weeks preceding surgery | – | 5.0 | 12 | 42.8 (10.5) | 66.3 | White = 92.5 | 46.7 (5.7) | − 41.3 (13.1) | 1 | ||
Look AHEAD (Johnson et al. 2017) 16 clinical sites across the USA [15] | Control | 2575 | Diabetes support and education | NR | – | 11.7 | 115 | Diabetes | 58.9 (6.9) | 59.7 | Black = 15.7 White = 63.3 Hispanic = 13.2 Other = 7.8 | 36.0 (5.8) | − 4.8 (7.3) | 358 |
Intervention | 2570 | Calorie restriction and exercise | 1200–1800 Based on guidelines of the ADA and National Cholesterol Education program | ≥ 175 min of moderate physical activity | 10.1 | 115 | 58.6 (6.8) | 59.4 | Black = 15.6 White = 63.1 Hispanic = 13.2 Other = 8.1 | 35.9 (6.0) | − 7.4 (8) | 373 | ||
Ma et al. 2013 California, USA [14] | Control | 81 | Usual care | NR | – | 18.5 | 15 | Pre-diabetes mellitus or metabolic syndrome | 52.5 (10.9) | 45.7 | White = 77.8 Asian/Pacific Islander = 17.3 Latino/Hispanic = 4.9 | 32.4 (6.3) | − 2.4 (8.1) | 0 |
Intervention | 160 | Coach lead exercise and self-directed exercise | Group Lifestyle Balance Program™ Lose 7% of weight through healthy eating | ≥ 150 min of moderate physical activities | 19.5 | 15 | 53.2 (10.5) | 46.9 | White = 78.1 Asian/Pacific Islander = 16.9 Latino/Hispanic = 3.8 | 31.7 (4.9) | − 5.4 (8.1) | 3 | ||
Ma et al. 2015 California, USA [19] | Control | 165 | Usual care | NR | – | 10.9 | 12 | Asthma | 47.7 (12.1) | 70.9 | White = 49.7 Black = 19.4 Asian/Pacific Islander = 8.5 Hispanic/Latino = 20.6 | 37.6 (5.7) | − 2.1 (10.3) | 0 |
Intervention | 165 | Weight loss intervention | 500–1000 kcal/d reductions, but daily total calories no less than 1200 kcal | ≥ 150 min moderate physical activity | 13.9 | 12 | 47.5 (12.6) | 70.3 | White = 49.7 Black = 20.6 Asian/Pacific Islander = 7.9 Hispanic/Latino = 20.0 | 37.4 (6.0) | − 4.0 (10.3) | 1 | ||
Maghrabi et al. 2015 Ohio, USA [10] | Control | 50 | Intensive medical therapy for diabetes | NR | – | 15.0 | 24 | Diabetes Dyslipidemia Hypertension | 50.0 (8.4) | 47.1 | Caucasian = 82.4 | 35.8 (3.0) | − 0.5 (4.1) | 4 |
Intervention | 100 | RYGB plus intensive medical therapy and laparoscopic sleeve gastrectomy plus intensive medical therapy | NR | – | 7.5 | 24 | 47.7 (9.7) | 64.3 | Caucasian = 67.4 | 36.3 (2.9) | − 23.9 (9.54) | 6 | ||
Villareal et al. 2011 St Louis, USA [17] | Control | 53 | Usual care and exercise | 1500 mg/day calcium and 1000 ID/day of vitamin D | 270 min 65% of their peak heart rate | 15.1 | 12 | Chronic disease | 69.5 (4.0) | 64.5 | White = 81 Black = 15 Other = 4 | 37.1 (5.0) | − 0.3 (3.52) | 3 |
Intervention | 54 | Weight loss and weight loss with exercise | Supplements as per controls. Energy deficit of 500 to 750 kcal/day. 1 g of high-quality protein/kg weight | 270 min 65% of their peak heart rate | 11.1 | 12 | 70.0 (4.0) | 61.0 | White = 88.5 Black = 11.5 Other = 0 | 37.0 (4.9) | − 9.1 (4.6) | 0 |
Bariatric Surgery Observational Studies
Author, year Location | Number | Intervention | Follow-up months | Comorbidities/medications | Age (years) mean (SD) | % female | BMI (kg/m2) mean (SD) | Fractures | Results (95% confidence interval) | |
---|---|---|---|---|---|---|---|---|---|---|
Axelsson et al. 2018 Sweden [20] | Control | 38,971 | Usual Care | 37.2 (median) | Comprehensive list of comorbidities, including the following: Diabetes Thyroid diseases Malnutrition Bone diseases Liver disease Renal diseases Bisphosphonates Hormone replacement | 41.0 (11.2) | 75.0 | NA | 774 | Hazard ratio- Reference category |
Bariatric surgery | 38,971 | A variety of bariatric surgical interventions | 37.2 (median) | 40.9 (11.2) | 76.4 | 42.4 (5.5) | 1019 | Adjusted hazard ratio for any fracture Patients with diabetes 1.26 (1.05–1.53) Patients without diabetes 1.32 (1.18–1.47) Adjusted for propensity score, age, sex, weight (only for patients with diabetes), height (only for patients with diabetes), rheumatoid arthritis, alcohol-related diseases, fracture-free time, any previous fracture, previous hip fracture, previous vertebral fracture, previous number of fractures, previous fall injury without fracture, previous osteoporosis, previous secondary osteoporosis, previous glucocorticoids (≥ 5 mg of prednisolone equivalents per day more than 3 months), previous calcium and vitamin D, Charlson comorbidity index | ||
Douglas et al. 2015 UK [21] | Control | 3882 | Usual care | 36 (median) | T2DM, hypertension, coronary heart disease, cerebrovascular disease, peripheral vascular disease, other atheroma, smoking status, alcohol consumption, and use of insulin, OADs, and statins | 45 (11) | 81.6 | 42.1 (6.5) | 32 | Hazard ratio- Reference category |
Bariatric surgery | 3882 | Gastric band, gastric bypass or sleeve gastrectomy | 36 (median) | 45 (11) | 80.5 | 44.7 (8.8) | 39 | Hazard ratio Any fracture 1.26 (0.79–2.01) All patients in the bariatric surgery group were propensity matched with the non-surgery patients with the closest propensity score when considering the following factors: age (within 2.5 years), sex, general practice, and presence in the CPRD on the date bariatric surgery was recorded | ||
Lalmohamed et al. 2012 UK [22] | Control | 10,442 | Usual care | 28 (mean) | Rheumatoid arthritis Cerebrovascular disease Smoking | 44.9 (11.2) | 85.3 | 40.8 (6.4) | 207 | Relative risk- Reference category |
Bariatric surgery | 2079 | A variety of bariatric surgical interventions | 26 (mean) | 44.6 (11.1) | 83.9 | 43.2 (7.2) | 38 | Adjusted relative risk for any fracture 0.89 (0.60–1.33) Adjusted for age, sex, and most recent record of body mass index before the index date; a history of fracture, inflammatory bowel disease, and cerebrovascular disease ever before; a history of falls in the previous 6–12 months; and use of glucocorticoids, calcium or vitamin D supplements, anti-obesity drugs, antihypertensive drugs, loop diuretics, organic nitrates, antidepressants, anxiolytics or hypnotics, bisphosphonates, opioids (tramadol or stronger), and proton pump inhibitors in the previous 6 months | ||
Lu et al. 2015 Taiwan [12] | Control | 5027 | Usual care | 59 (mean) | Diabetes Hypertension Hyperlipidemia | 31.9 (9.9) | 63.7 | – | 374 | Adjusted hazard ratio- Reference category |
Bariatric surgery | 2064 | A variety of bariatric surgical interventions | 57 (mean) | 31.8 (9.2) | 64.4 | – | 183 | Adjusted hazard ratio for any fracture 1.21 (1.01–1.44) Adjusted for duration of follow-up, material and social deprivation, area of residence, history of fractures (analysis for period after index date only), and number of comorbidities in the previous 5 years | ||
Nakamura et al. 2014 Minnesota, USA [23] | Control | – | – | – | – | – | – | – | – | Standardized Incidence Ratio- Reference category |
Bariatric surgery | 258 | A variety of bariatric surgical interventions | 107 (mean) | 43.6 (9.9) | 82.2 | 49.0 (8.4) | 79 | Standardized incidence ratio for any fracture 2.3 (1.8–2.8) Expected numbers were derived by applying age and sex-specific fracture incidence rates in the general population of this community to the age specific person-years of follow-up | ||
Rousseau et al. 2016 Quebec, Canada [13] | Control | 126,760 | Non-obese | 53 (mean) | Cardiovascular disease Hypertension Chronic pulmonary disease Diabetes Hypothyroidism Renal failure Depression Osteoporosis | 42.6 (11) | 72.3 | – | 3008 | Adjusted relative risk- Reference category |
Control | 38,028 | Obese without bariatric surgical intervention | 42.7 (11) | 1013 | Adjusted relative risk- 1.04 (0.96 to 1.12) Adjusting for duration of follow-up, social deprivation, area of residence, history of fractures (analysis for period after index date only), and number of comorbidities in the previous 5 years, using multivariate conditional Poisson regression model | |||||
Bariatric surgery group | 12,676 | A variety of bariatric surgical interventions | 42.6 (11) | 514 | Adjusted relative risk- 1.44 (1.29 to 1.59) |