The need to move beyond BMD alone and adopt comprehensive, individualized approaches to fracture risk assessment and management in obesity is highlighted.
Abstract
The relationship between obesity and bone health is increasingly recognized as complex and paradoxical. Despite higher bone mineral density (BMD) in individuals with obesity, fracture risk is not uniformly reduced. Instead, fractures tend to occur more frequently at peripheral sites such as the ankle, humerus, and tibia, indicating a mismatch between BMD and true bone strength. In the early stages of weight gain, mechanical loading and adipose-derived hormonal factors may promote bone formation. However, these effects are progressively counterbalanced by chronic inflammation, oxidative stress, and marrow adiposity, which impair bone quality and compromise microarchitecture. Conventional dual-energy X-ray absorptiometry (DXA), while central to clinical assessment, cannot capture these changes and may overestimate skeletal strength in the presence of excess soft tissue. Emerging tools such as trabecular bone score and high-resolution peripheral quantitative computed tomography provide additional insights into bone quality, including microarchitecture and cortical porosity, particularly in individuals with type 2 diabetes. Obesity is also associated with vitamin D deficiency, impaired muscle function, and sarcopenic phenotypes, further increasing fracture risk. Bariatric surgery introduces additional challenges by accelerating bone turnover and loss. This review highlights the need to move beyond BMD alone and adopt comprehensive, individualized approaches to fracture risk assessment and management in obesity.
Background
Obesity has been considered protective against osteoporosis due to its association with higher bone mineral density (BMD). However, metabolic dysfunction, particularly insulin resistance (IR), may compromise bone quality even with BMD preserved.
Methods
This retrospective cross-sectional study (n=254) included 153 individuals with severe obesity undergoing bariatric metabolic surgery and 101 age- and sex-matched non-obese controls. BMD and trabecular bone score (TBS) were measured using dualenergy X-ray absorptiometry. A subgroup of participants with obesity was further analyzed to examine associations between IR, assessed using the homeostasis model assessment of insulin resistance (HOMA-IR), and bone parameters.
Results
BMD was significantly higher in the obese group, indicating preserved bone mass in obesity. But the proportions of spine-hip Z-score discordance was significant higher in the obese group (P=0.001). TBS displayed sitespecific findings: TBS at L1 was significantly higher in the obese group (P=0.002), whereas no significant differences were observed at L2-L4. Partially degraded or degraded TBS were higher in the obese group (P=0.021). Among participants with obesity, TBS decreased progressively across HOMA-IR quartiles (P=0.043), whereas BMD remained stable. In multivariable regression, higher HOMA-IR was independently associated with lower TBS (β=-0.0025; 95% confidence interval, -0.0043 to -0.0006; P=0.015), although this association was attenuated by hemoglobin A1c adjustment.
Conclusion
Patients with obesity demonstrated site-specific reductions in trabecular bone quality, particularly in the lower lumbar spine compared with non-obese people. IR was independently and inversely associated with TBS, suggesting that metabolic dysfunction, not mechanical loading, influences bone fragility in obesity. TBS represents a valuable adjunct to BMD for assessing skeletal health in metabolically impaired obese populations.
Taehoon Park, K. Seo, Ki Hyun Kim et al.· Endocrinology and Metabolism· 0 citations
Osteoporosis is increasingly recognized as an immune-mediated condition (“immunoporosis”), yet data on bone health in adults with primary immunodeficiencies (PIDs) remain limited. Chronic immune dysregulation and multisystem complications in PIDs may adversely affect skeletal integrity, but bone microarchitecture and muscle mass have not been comprehensively evaluated in this population. The aim of our study was to assess bone mineral density (BMD), trabecular bone score (TBS), and muscle mass in adults with PIDs. Exploratory analyses examined associations between these measures and clinical features and the main peripheral blood lymphocyte subsets.
In this single-center cross-sectional study, 61 adult patients with PIDs underwent dual-energy X-ray absorptiometry (DXA) of the lumbar spine, total hip, femoral neck, and whole body. TBS was derived from lumbar spine DXA images, and the appendicular lean mass index was calculated to assess muscle mass. Clinical characteristics and immunological parameters, including peripheral blood lymphocyte subsets, were analyzed in relation to skeletal outcomes.
Based on age-appropriate DXA findings and clinical data, osteoporosis was diagnosed in 12 of 61 patients (19.7%). Three additional patients were diagnosed based on fragility fractures, increasing the overall prevalence to 15 of 61 (24.6%). Low BMD was more frequently detected at the hip than at the lumbar spine. Partially degraded or degraded TBS was observed in 15 of 61 patients (24.6%). Low muscle mass was identified in 17 of 61 patients (27.9%) and was associated with significantly lower BMD at all skeletal sites. Participants with bronchiectasis had lower femoral neck and total hip BMD and lower TBS, whereas those with enteropathy had lower BMD across all skeletal sites and lower TBS. Among participants eligible for T-score assessment (n = 15), NK-cell counts correlated positively with femoral neck (ρ = 0.63, p = 0.01) and total hip T-scores (ρ = 0.68, p < 0.01), and with TBS in the entire cohort (n = 61; ρ = 0.28, p = 0.03). CD4+, CD8+, and CD19+ cell counts were not associated with any evaluated densitometric parameters.
In this cohort of adults with PIDs, reduced BMD and impaired TBS represented distinct, partially overlapping findings. Hip DXA appeared particularly informative, while TBS provided complementary information beyond BMD. These exploratory findings should be confirmed in prospective controlled studies.
A. Nowakowska-Płaza, J. Wroński, A. Zegadło et al.· Frontiers in Endocrinology· 0 citations
Low bone density is a significant health concern among perimenopausal women, contributing to increased risk of osteoporosis and fractures. This review synthesizes current evidence from recent articles to elucidate the etiology, risk factors, diagnostic approaches, and management strategies related to low bone density during the perimenopausal period. Hormonal fluctuations, particularly declining estrogen levels, play a pivotal role in bone resorption surpassing formation, leading to decreased bone mineral density (BMD). Additional factors such as nutritional deficiencies, sedentary lifestyle, smoking, excessive alcohol consumption, and genetic predispositions further exacerbate bone loss. Diagnostic tools like dual-energy X-ray absorptiometry (DXA) are essential for early detection. Preventive and therapeutic interventions, including lifestyle modifications, calcium and vitamin D supplementation, and pharmacologic treatments like bisphosphonates, are discussed. Emphasizing early identification and comprehensive management can mitigate long-term skeletal complications, improving quality of life in perimenopausal women. Future research directions focus on personalized treatment approaches and understanding molecular mechanisms underlying bone density changes during this transitional phase.
Runna Bhattacharjee· International Journal For Mu...· 0 citations
In postmenopausal women, higher BMI was associated with higher BMD but lower TBS, supporting a divergent relationship between densitometric findings and DXA-derived trabecular texture parameters, and suggesting that TBS may complement BMD in describing skeletal imaging status in overweight and obese women.
Effective care in cases of male osteoporosis requires an integrated risk-based approach that extends beyond BMD to include clinical risk factors, secondary causes, and functional status, and improved recognition and sex-specific management strategies are essential to reduce the fracture burden and improve long-term outcomes in men.
Selin Tekin, Alper Gürlek· Turkish Journal of Medical S...· 0 citations
A practical clinical framework is proposed that integrates endocrine phenotype, vertebral imaging, trabecular bone score, and biochemical assessment into fracture-risk stratification and therapeutic decision-making, enabling improved identification of high- and very-high-risk patients and facilitating the appropriate use of anabolic and antiresorptive therapies.
I. Cincione, Robert A. Marcantonio, Marcellino Monda et al.· Frontiers in Endocrinology· 0 citations
