SHORT COMMUNICATION

Is obesity protective for osteoporosis? Evaluation of

bone mineral density in individuals with high body mass
index
E. A. Greco,1,3* R. Fornari,1* F. Rossi,1 V. Santiemma,1 G. Prossomariti,2 C. Annoscia,1 A. Aversa,1
M. Brama,1 M. Marini,2 L. M. Donini,1,3 G. Spera,1 A. Lenzi,1 C. Lubrano,1  S. Migliaccio1 

1
Dipartimento di Fisiopatologia
SUMMARY
What’s known Medica, ‘Sapienza’ Università di
Background: Obese individuals often present comorbidities while they appear Women with high body mass index seem to be Roma, Policlinico Umberto I,
Rome, Italy
protected against the development of osteoporosis. However, few and contradic- protected against osteoporosis. However, merging 2
Scienze Radiologiche,
tory data are now available on skeletal modifications in obese patients. The aim data on this issue are conflicting.
‘Sapienza’ Università di Roma,
of this study was to characterise bone mineral density (BMD) in overweight (BMI What’s new Policlinico Umberto I, Rome,
> 25 < 29.9) and obese (BMI > 30) patients. Methods: We selected 398 Italy
Morbid obesity may not be always considered as a 3
Istituto Clinico Riabilitativo
patients (291 women, 107 men, age 44.1 + 14.2 years, BMI 35.8 + 5.9 kg ⁄ m2) protective factor against osteoporosis in both
‘Villa delle Querce’, Nemi, Italy
who underwent clinical examination, blood tests and examination of body compo- female and male populations. The assessment of
sition. Subjects with chronic conditions or taking medications interfering with bone skeletal metabolism in severe obesity is Correspondence to:
metabolism, hormonal and nutritional status and recent weight loss were excluded. recommended. Dr Silvia Migliaccio, MD, PhD,
Dipartimento di Fisiopatologia
Results: Interestingly, 37% (n = 146) of this population showed a significantly Medica, ‘Sapienza’ Università di
lower than expected lumbar BMD: 33% (n = 98) of women showed a T-score Roma, Policlinico Umberto I,
)1.84 ± 0.71, and 45% (n = 48) of men showed a T-score )1.88 ± 0.64. When Viale del Policlinico155, 00161
the population was divided into subgroups based on different BMI, it was noted Rome, Italy
Tel.: + 39 06 49970721
that overweight (BMI > 25 < 29.9) was neutral or protective for BMD, whereas Fax: + 39 06 4461450
obesity (BMI > 30) was associated with a low bone mass, compatible with a diag- Email:
nosis of osteoporosis. No differences were observed in hormones and lipid profiles silvia.migliaccio@uniroma1.it
among subgroups. Conclusions: Our results indicate that a subpopulation of
Disclosure
obese patients has a significant low lumbar BMD than expected for age. Thus, a None.
careful characterisation of skeletal metabolism might be useful in all obese individ-
uals to avoid fragility fractures later in life. *The contribution of the first
two authors must be
considered equal.
apparently exerting protection against bone loss after
Introduction
menopause (8,9). The pathophysiological relevance  The contribution of the last
two authors must be
Obesity and osteoporosis are two increasing health of adipose tissue for skeletal integrity probably
considered equal.
problems in many countries (1–3). Overweight resides in the role of several adipokines in bone
results when energy intake exceeds energy expendi- remodelling through effects on both formation and
ture for a considerable period of time. Obese resorption. Recently, bone has been considered an
individuals are often affected by hypertension, dyslip- endocrine organ affecting body weight control and
idaemia, diabetes mellitus (4,5) and cardiovascular glucose homoeostasis through the actions of bone-
diseases (CVD) such as coronary heart disease and derived factors such as osteocalcin and osteopontin
stroke (1–5). Osteoporosis is a bone metabolic dis- (10–12). The cross-talk between fat and the skeleton
ease characterised by skeletal fragility, leading to an constitutes a homoeostatic feedback system in which
increased risk of developing spontaneous and trau- adipokines and molecules secreted by osteoblasts and
matic fractures (6). Both osteoporosis and obesity osteoclasts represent the link of an active bone–adi-
have been defined as social diseases because of their pose axis (10–12). However, the mechanism(s) by
high impact on mortality and morbidity, and of the which all these events occur remains unclear. In
alterations in the quality of life of patients affected particular, even though several data indicate that
by these two diseases (7). women with high BMI (25–29.9 kg ⁄ m2) are pro-
Interestingly, body fat and lean mass are correlated tected from osteoporosis (8,9), an increasing number
with bone mineral density (BMD), with obesity of evidence (13) seems to show conflicting results

ª 2010 Blackwell Publishing Ltd Int J Clin Pract, May 2010, 64, 6, 817–820
doi: 10.1111/j.1742-1241.2009.02301.x 817
818 Severe obesity and bone mineral density in men and women
regarding this issue, suggesting that obesity (BMI
> 30) might actually interfere with bone health.
The aim of this study was to evaluate BMD in a
cohort of patients ranging from overweight (BMI =
25–29), to morbid obesity (BMI > 40) and to assess
whether subpopulations of these patients might be at
higher risk for skeletal alterations such a decrease in
BMD.
Patients and methods
In this study, 398 patients (291 women, 107 men;
mean age 41 + 14 years; mean BMI 35.8 + 5.9 kg ⁄ m2)
were selected from overall 500 patients admitted to
our Department for overweight ⁄ obesity. The study
received the approval of the Internal Review Board of
our Institution. Exclusion criteria were chronic medi-
cal conditions or the use of medications affecting bone
metabolism, recent weight loss, hormonal and nutri-
tional status and prior bariatric surgery interventions.
Patients underwent complete medical history and
clinical examination and while lipid profile, glucose
metabolism, cytokines, calciotropic hormones and
bone turnover markers were measured by standard
methods as previously published elsewhere (13).
Body fat, lean mass and BMD were measured by
Dual-Energy-X-Ray Absorptiometry (DXA) (Hologic
4500 RDR), with coefficient of variation of < 1% for
bone density and < 1.5% for fat mass (13). In this
study, only vertebral BMD was considered because of
the young age of the subjects.
Anthropometric measurements included weight
and height. Body mass index (BMI) was calculated as
weight (kg) ⁄ height (m2) and subjects were divided
into subgroups according to their different BMI:
Overweight (OW, BMI = 25–29.9); Obesity, also
named mild obesity (MO, BMI = 30–40) and severe
obesity (SO, BMI ‡ 40).
Results are expressed as mean ± standard devia-
tion (M ± SD) and compared by means of ANOVA
for repeated measures and least significant difference
test (planned comparison). Differences were consid-
ered statistically significant when p < 0.05 was
found.
Results
Conflicting results exist regarding the protective role
of obesity against osteoporosis. In our study, we
demonstrated for the first time that 37% (n = 146)
of the evaluated population had significant skeletal
alterations in the presence of obesity. In particular,
this population had a low mineral bone density (at
lumbar spine BMD of 0.889 ± 0.118 g ⁄ cm2; T-score
)1.85 ± 0.68) expected for both age and high BMI.
ª 2010 Blackwell Publishing Ltd Int J Clin Pract, May 2010, 64, 6, 817–820
100 Total study population
90
80
Normal BMD
70 Osteopenia
60 Osteoporosis
50
40
30
20
10
0
OW Mild OB Severe OB
BMI
Figure 1 Bone mineral density in the total population
(women and men). Data are presented as % of total
(100%)
In particular, 29% of the individuals had a low BMD
consistent with osteopenia, whereas 8% had a low
BMD consistent with osteoporosis, as shown in
Figure 1. Interestingly, no significant differences were
found between obese female and male individuals, as
shown in Figure 2.
More specifically, 45% (n = 48) of the male popu-
lation showed a modification in lumbar BMD
0.92 ± 0.16 g ⁄ cm2 with a T-score )1.88 ± 0.64.
Going into further details, 55% had normal BMD,
35% showed osteopenia and 10% showed osteoporo-
sis and, surprisingly, this latter group had mean age
younger than that of the other groups. Considering
the results obtained in the female population
(n = 291), it was observed that 67% of the popula-
tion had a normal BMD, whereas the 33% (n = 98)
showed a lumbar T-score of )1.84 ± 0.71 (BMD of
0.876 ± 0.083 g ⁄ cm2) so that 26% of women present
osteopenia while 7% present osteoporosis.
After this first evaluation, to further investigate
whether different grades of adiposity could differ-
ently affect the skeletal health status, the population
was subdivided into three different groups depending
on BMI, as shown in Table 1. This characterisation
of the population allowed to appreciate a slightly dif-
ferent pattern of BMD distribution among groups
(Figure 2). Subjects in the first group (overweight)
did not show any modification in skeletal health,
with higher per cent of individuals having normal
BMD and a low number of individuals with osteope-
nia ⁄ osteoporosis, confirming a protective role of
slight weight excess (BMI > 25 < 30) for the skele-
ton, as previously shown in the literature (8,9,15).
In contrast, obese and severely obese subjects (BMI
> 30) showed a significant alteration in their BMD
levels, with an increased number of individuals having
a low bone mass expected for age. Evaluation of hor-
monal, metabolic and lipid profile did not show signif-
icant differences among groups (data not shown).
 Severe obesity and bone mineral density in men and women 819

100
Female 100
Male
90 90
80 Normal BMD 80 Normal BMD
Osteopenia Osteopenia
70 70
Osteoporosis Osteoporosis
60 60
50 50
40 40
30 30
20 20
10 10
0 0
OW Mild OB Severe OB OW Mild OB Severe OB
BMI BMI

Figure 2 Population is divided in women (left panel) and men (right panel). Each population is subdivided in group
upon grade of obesity as explained in Table 1 and in Results and Discussion

Table 1 Characteristics of the examined population

Normal Osteopenic Osteoporotic Total Age

Female population (n = 305)

BMI 25–29.9 15 18 5 38 46 ± 16.2
BMI 30–39.9 120 74 11 185 46 ± 14
BMI > 40 53 18 11 82 44 ± 13
Male population (n = 83)
BMI 25–29.9 11 7 2 20 51.4 ± 12
BMI 30–39.9 22 22 4 48 42 ± 13
BMI > 40 5 7 3 15 38 ± 12

conditions (8,9). However, recent studies show that

Discussion
In accordance with recent studies, our results show
that a subpopulation of obese patients has signifi-
cant reduction in bone mineral mass for age
and for BMI. These surprising results could be
explained by hypothesising that obesity could be
considered an inflammatory status as also suggested
by increased level of C-reactive protein, also associ-
ated with increased production of proinflammatory
cytokines (data not shown), some of which are os-
teoclastogenetic (manuscript in preparation). In
addition, we do not know at the present time
whether some of the individuals evaluated might
have a condition of subclinical hypercortisolism,
which could worsen bone health status in these
individuals affected by morbid obesity.
Indeed, obesity is considered the most important
risk factor for CVD such as heart failure and stroke
(14), resulting from the significant metabolic changes
associated with fat deposition in subcutaneous and
visceral deposits (1–5).
Traditionally, osteoporosis has been considered as
a condition only associated with fractures in old
individuals and not related to other pathological
BMD seems to be an important long-term predictor
of death (15,16). Furthermore, low BMD is a strong
and independent predictor of cardiovascular mortal-
ity, particularly in men (15,16). Thus, these data,
taken together, suggest that a potential association
exists between osteoporosis and CVD, which deserves
further characterisation and focus (17,18).
Indeed, in overweight or obese individuals weight
reduction of 10% is recommended as it appears an
achievable goal able to reduce comorbid risk factors
(19). However, some data show that in 10% weight
loss results in 1–2% bone loss at different bone
sites (20–23) even though the bone loss appears
greater in normal-weight individuals compared with
that in overweight or obese individuals (24). More-
over, weight loss and weight-cycling throughout
adulthood have been shown to increase hip fracture
risk (25), thus further suggesting a strong correlation
between fragility fractures and pathological accumu-
lation of adipose tissue.
In conclusion, this study provides a new clinical
evidence that morbid obesity may not be considered
as a protective factor against osteoporosis in both
female and male populations. Our results suggest a

ª 2010 Blackwell Publishing Ltd Int J Clin Pract, May 2010, 64, 6, 817–820
820 Severe obesity and bone mineral density in men and women

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ª 2010 Blackwell Publishing Ltd Int J Clin Pract, May 2010, 64, 6, 817–820