# Management of Adverse Skeletal Effects Following Bariatric Surgery Procedures in People Living with Obesity

## TL;DR

This review discusses how to manage bone health issues in people who have undergone bariatric surgery, focusing on lifestyle changes and medications like zoledronic acid.

## Contribution

The paper provides updated guidelines and evaluates the effectiveness of antiosteoporosis medications in managing post-bariatric surgery skeletal effects.

## Key findings

- Zoledronic acid is recommended as the preferred treatment for osteoporosis after bariatric surgery.
- Lifestyle changes, including calcium, vitamin D, protein intake, and resistance training, are crucial for bone health.
- Denosumab is suggested as a second-line treatment when bisphosphonates are unsuitable.

## Abstract

This review focuses on recent findi+ngs regarding the management of adverse skeletal effects following weight loss in people living with obesity (PwO). We summarize the guidelines provided by various societies for the prevention and treatment of osteoporosis resulting from bariatric surgery. Next, we discuss the use of traditional antiosteoporosis medications in this population.

Guidelines for preventing and treating osteoporosis resulting from bariatric surgery have been recently provided by various societies setting specific treatment criteria for postmenopausal women and men aged ≥ 50 years, based on the occurrence of fragility fractures and/or T-score thresholds. Several studies have highlighted the positive effects of lifestyle changes in preventing high-turnover bone loss; however, data on fracture outcomes are currently unavailable. It is generally accepted that following bariatric procedures, sufficient intake of calcium, vitamin D, and protein, along with regular exercise incorporating progressive, supervised resistance training, is crucial to counteract negative impacts on bone. Regarding the need for medications to combat osteoporosis, most societies recommend zoledronic acid as the preferred choice. This preference is due to the problems associated with oral bisphosphonates, including poor tolerance and absorption issues. Denosumab is typically considered the second choice when bisphosphonates are not suitable or well tolerated. Two randomized controlled studies have recently demonstrated the effectiveness and safety of zoledronic acid and denosumab in addressing high-turnover bone loss.

Although guidelines exist for managing skeletal health before and after bariatric surgery, more research is required to validate these recommendations and the use of anti-osteoporosis medications.

The online version contains supplementary material available at 10.1007/s11914-025-00902-9.