Global prevalence and risk factors of osteoporosis in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis
Osteoporosis (OP) is a common comorbidity in patients with chronic obstructive pulmonary disease (COPD), but reported prevalence estimates vary substantially across studies, and the magnitudes of associations between OP and potentially modifiable factors remain uncertain. This systematic review and meta-analysis aimed to provide an updated estimate of the prevalence of OP among patients with COPD, explore potential sources of heterogeneity, and synthesise adjusted associations with selected clinical factors. EMBASE, CINAHL, Scopus, PubMed, and the Cochrane Library were searched from inception to 5 February 2026. Only observational studies published in English involving adults with objectively diagnosed COPD and reporting OP prevalence or associated factors were included. Two reviewers independently conducted study selection, data extraction, and quality assessment using the Newcastle–Ottawa Scale or the AHRQ assessment tool. Random-effects models were used for all quantitative syntheses. Risk-factor analyses were based exclusively on adjusted ORs. Subgroup analyses, leave-one-out sensitivity analyses, and univariable meta-regression were used to explore heterogeneity. Eighty-seven studies involving 1,453,879 patients with COPD were included. The pooled prevalence of OP was 33.8% (95% CI 31.4%–36.1%), with extremely high between-study heterogeneity (I²=99.7%). Prevalence estimates varied geographically, ranging from 28.7% in Europe and 28.8% in Africa to 42.3% in North America. The methodological quality score was significantly associated with variation in prevalence estimates in univariable meta-regression ( P < 0.001), although substantial residual heterogeneity remained. Underweight was associated with higher odds of OP (OR = 3.91, 95% CI 1.36–11.24). Corticosteroid exposure was also associated with OP (OR = 2.85, 95% CI 1.45–5.59). In an exploratory analysis based on two studies involving 172 participants, cumulative systemic corticosteroid exposure exceeding 1,000 mg prednisone-equivalent was associated with higher odds of OP (OR = 7.36, 95% CI 1.70–31.98). Higher FEV₁% predicted was associated with lower odds of OP (OR = 0.97, 95% CI 0.96–0.98). No statistically significant associations were identified for age ≥ 65 years or overweight status. OP affects approximately one-third of patients with COPD across the included studies. Underweight, corticosteroid exposure, and reduced lung function were associated with OP, but the findings should be interpreted cautiously because of extreme residual heterogeneity, differences in covariate adjustment, and limited evidence available for some subgroup analyses. Standardised diagnostic methods and better reporting of clinical, treatment-related, and sociodemographic characteristics are needed to improve future risk estimation. CRD420261381268.