The Impact of Roux-en-Y Gastric Bypass on Bone Remodeling Expressed by the P1NP/βCTX Ratio: a Single-Center Prospective Cohort Study

Obes Surg. 2019 Apr;29(4):1185-1194. doi: 10.1007/s11695-018-03640-3.


Background: Bariatric surgery seems to decrease bone mineral density and increase the risk of fatigue fractures. P1NP (bone formation) and βCTX (bone resorption) were recently validated as reference bone turnover markers (BTM).

Objective: To assess changes in bone remodeling in severely obese patients undergoing Roux-en-Y gastric bypass (RYGB) by using a new composite biomarker, the P1NP/βCTX ratio.

Methods: We prospectively collected blood samples preoperatively, at 1 month and at 1 year from 114 consecutive RYGB patients from 12/2012 to 04/2014. Repeated measures ANOVA and multiple regression were used for data analysis. Cumulative incidence of fractures was assessed in 06/2018.

Results: The P1NP/βCTX ratio decreased significantly (P < 0.001) from baseline to 1 month and 1 year (180 ± 6.6, 110 ± 4.1, and 132 ± 5.4). The 1-year P1NP/βCTX ratio did not correlate with BMI or ΔBMI, but inversely correlated with age (r = - 0.23, P = 0.014) and with hsCRP (r = - 0.26, P = 0.009), even after adjustment for age, sex, BMI, and lifestyle, and linearly correlated with albumin (r = 0.2, P = 0.037). At baseline, none of these correlations were detectable. Serum for all time-points was available from > 94% of the patients. At a median follow-up of 4.7 years, 8 patients (7.3%) had a bone fracture, all of them traumatic.

Conclusion: Following RYGB, bone remodeling increases, with a shift toward degradation. This effect seems to be weight-loss independent and shows a correlation with age, with the level of systemic inflammation, and with nutritional state. The risk of fractures should be assessed systematically in bariatric patients and measures of prevention should be improved accordingly.

Keywords: Bone remodeling; Bone turnover markers; P1NP/βCTX ratio; Parathyroid hormone; Roux-en-Y gastric bypass; Systemic inflammation; Vitamin D.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Biomarkers / blood
  • Bone Density
  • Bone Remodeling* / physiology
  • Cohort Studies
  • Collagen Type I / blood*
  • Female
  • Follow-Up Studies
  • Gastric Bypass* / methods
  • Humans
  • Male
  • Middle Aged
  • Obesity, Morbid / blood*
  • Obesity, Morbid / physiopathology
  • Obesity, Morbid / surgery*
  • Peptide Fragments / blood*
  • Peptides / blood*
  • Procollagen / blood*
  • Prospective Studies
  • Weight Loss / physiology


  • Biomarkers
  • Collagen Type I
  • Peptide Fragments
  • Peptides
  • Procollagen
  • collagen type I trimeric cross-linked peptide
  • procollagen Type I N-terminal peptide