- Research
- Open access
- Published:
The inter-relationship of the triad: osteoporosis, fracture risk, and obesity—a longitudinal multicenter analysis by the Egyptian Academy of Bone Health
Egyptian Rheumatology and Rehabilitation volume 51, Article number: 7 (2024)
Abstract
Purpose
To assess the relationship between the triad of obesity, fracture risk factors, and osteoporosis and its impact on fragility fractures.
Results
Osteoporosis was least prevalent (p < 0.001) among the obese patients in comparison to overweight and normal body mass index patients. On the other hand, history of risk of falling as well as history of fall(s) in the last year, sarcopenia, and functional disability were significantly more prevalent (< 0.01, 0.05, and 0.05 respectively) among the obese patient cohort.
Conclusion
Obesity was found to be associated with higher bone mineral density of the hip, lumbar spine, and distal forearm. This was significantly different in post-menopausal women, but not in men. Covariates such as sarcopenia, falls risk, and functional disability play an important factor in making the patient at high risk and prone to develop a fragility fracture.
Background
The pace of population aging is much faster than any time passed. By 2050, worldwide, the number of older adults over 60 years old is expected to double (from 901 million in 2015 to 2.1 billion); 80% of them will be in low- and middle-income countries [1]. However, it is necessary that longevity is associated with healthy aging. Globally, the incidence of osteoporosis-related fractures has been predicted to increase with the expansion of aging population [2, 3]. In concordance, aging was reported to be associated with an increase in truncal obesity, a major contributor to metabolic syndrome and insulin resistance. Consequently, obesity has been linked to several of the age-related diseases and thus has become a serious concern for both the population and the policy makers [4]. Together, osteoporosis and obesity have been linked with excess mortality [5,6,7], besides being among the commonest causes of disability and morbidity worldwide [8].
Obesity was previously thought to have positive effect on age-related osteoporosis as overweight individuals possess higher bone mineral density. This positive effect has been explained by the high mechanical loading on bones, higher bone mineral density, and fat padding effect around the hips [9,10,11,12]. However, this assumption has recently been increasingly questioned. Lack of association between risk of vertebral fracture and body mass index (BMI) was reported in a meta-analysis of 6 studies [13]. Furthermore, several clinical risk factors besides age, gender, and menopausal status have been suggested as covariates that might have an impact on the development of low trauma fractures [14, 15]. This study examines the relationship between the triad of obesity, fracture risk factors, and osteoporosis and its impact on fragility fractures.
Methods
Study population
This was a population-based multicenter cross sectional prospective epidemiological study. Men and women of 50 years old and older who presented with a fragility fracture and managed under the fracture liaison service (FLS) program in Egypt were recruited for this work consecutively. All the patients were managed and monitored prospectively according to the Egyptian FLS standards [16]. Longitudinal analysis of the currently accessible 2-year data (2021–2023) recorded on the national register was carried out.
Case definition
Patients 50 + years old who attended the trauma clinic/accident and emergency as well as those who were admitted to the hospital with fragility fractures whether major osteoporotic fracture or hip fracture were recruited for this study.
Eligibility criteria
Inclusion criteria: Egyptian patients, either male or female, above 50 years of age, presenting with fragility fractures.
Exclusion criteria: we excluded persons with pathological fractures, with history of high impact trauma, and those on anti-osteoporotic medications.
Patients’ assessment
Clinical evaluation
All patients were subjected to the following: (a) a structured baseline questionnaire that included complete history, including smoking history, alcohol use, current medications, previous fracture, or parents’ history of fracture; (b) general clinical examination including the calculation of BMI and review of systems—according to the BMI, in kg/m2, patients were classified into 4 classes: underweight (< 18.49), normal weight (18.5–24.99), overweight (25.0–29.9), and obese class I/II (> 30.0) [13]—(c) evaluation of the musculoskeletal system; (d) assessment of risk factors for fragility fractures including fracture risk assessment (FRAX) factors; (e) fall risk assessment was done using the falls risk assessment (FRAS) questionnaire [17]; (f) sarcopenia risk using sarcopenia self-reported (SARC-F) questionnaire [18]; (g) functional disability using Health Assessment Questionnaire (HAQ) [19].
Evaluation of bone mineral density
Dual x-ray absorptiometry (DXA) scanner was used to measure the bone mineral density (BMD) at two sites:the lumbar spine (L1 through L4) and non-dominant hip (femoral neck, trochanter, and total hip)—and Z-scores and T-scores were scored.
In case the patient may have more than one fragility fracture, analyses were adjusted for baseline FRAX parameters recorded at the time of first fragility fracture.
Outcomes
The primary outcome was comparison of fracture risk as identified by FRAX (Egypt FRAX) [20] (https://www.fraxplus.org/calculation-tool/) and bone mineral density in relation to the body mass index stratified into 3 categories: normal, overweight, and obese. Secondary outcomes were as follows: (1) assessing whether there are gender differences in relation to the body mass index and fracture risks and bone mineral density; (2) what are the co-variants that might affect the relation between the BMI and osteoporotic fractures.
Statistical analysis
Statistical analyses were performed using the 26th version of SPSS. Data was checked for missing and consistency before statistical analysis was conducted. All collected categorical data were described as frequency and percentages. Quantitative data were described as mean and standard deviation. Chi-square test was used for categorical variables to compare between different groups, and p value was always set at ≤ 0.05. Additionally, multivariate regression analysis was performed, Omnibus test was used to test the significance, and Hosmer and Lemeshow test was used for goodness of fit.
Results
Basic characteristics
Two hundred sixty-four patients were included in this study, 72 males and 192 females. The mean age of the men was 70.5 ± 9.415 years, whereas the mean age of the women was 71.03 ± 9.389 years. Analysis of the patients’ data revealed that no patients with chronic liver or kidney diseases were included in the study. Glucocorticoid dose taken by the patients included in the study was in the range of 2.5–5 mg; there were no patients taking oral glucocorticoids more than 5 mg/day. Data showing systemic diseases as well as history of smoking among the patients included in the study are demonstrated in Table 1. Osteoporosis was the least prevalent among the obese patients in comparison to overweight and normal BMI patients (Table 2). On the other hand, history of fall(s) in the previous year, sarcopenia, and functional disability were more prevalent among the obese patient cohort.
DXA scan results and gender differences
BMD was significantly higher in obese postmenopausal women at all sites: forearm, spine, hip, and neck of the femur (Table 2). In contrast, in men, there was no difference on comparing the BMD between the obese, overweight, and normal BMI patients. Table 4 shows a comparison of the fracture risks among the males and females included in this study stratified according to their BMI.
Risk factors
Although the fracture risk was lower in obese patients (Tables 2 and 3), sarcopenia risk, functional disability (Tables 3 and 4), and falls risk (Table 5) were significantly higher in the obese patients in comparison to the overweight and normal weight patients.
Though osteoporosis, defined as t-score ≤ 2.5, was less encountered among obese (p < 0.01), the incidence of fracture was higher but not significant among obese patients compared to the overweight and non-obese (47.8%, 46% and 33% respectively). Moreover, multivariable regression analysis showed no significant independent effect of obesity on the incidence of fracture controlling for smoking and parental history of fracture. The model was found to be significant (Omnibus test p value = 0.031), and Hosmer and Lemeshow test for goodness of fit was found to be insignificant (p = 0.955). The model was able to explain 60.7% of the variability in the incidence of fracture (Table 6).
Discussion
Aging and obesity are two sides of the same coin. By middle age, obesity predisposes an individual to age-related conditions, illness, and disease. Later, in older adult stage, obesity may cause the muscles to age faster, and for its impact on the person’s activities of daily living as well as systemic health, it enhances frailty and consequently fractures. The aim of this study was to assess the relationship between the triad of obesity, fracture risk factors, and osteoporosis and its impact on fragility fractures.
This study showed that, though the prevalence of osteoporosis was significantly less in obese and overweight patients, there was no statistically significant difference in the incidence of fragility fractures in relation to the BMI category. Therefore, the high bone mineral content seems not enough as a protective factor on the fracture risk. Results of this work agree with the outcomes of previous studies which documented the positive association between obesity and high bone mass [21,22,23]. This was attributed to increased levels of the obesity-related insulin, leptin, and estrogen which inhibit bone remodeling and stimulate bone growth. This protective effect of obesity is called the “obesity paradox” or “reverse epidemiology” [24]. On the other hand, a negative association between body mass and osteoporosis has been reported in other studies [25,26,27,28,29].
The prevalence of osteoporosis and the rate of fractures revealed gender differences in the studied cohort of patients. The total fat mass was positively associated with high BMD; hence, the obesity paradox was only found in postmenopausal women and not in men. Yet, there was a significant difference in men reflecting higher prevalence of low impact trauma fractures in comparison to women. A relatively few research studies have included both genders aiming to assess gender-based dissimilarities in the association between BMD and the obesity paradox which remains controversial. Ley et al. [30] attributed this to the difference in body fat distribution between males and females. In contrast, Katzmarzyk et al. [31] did not report any gender differences between BMD and either abdominal subcutaneous tissue or visceral adiposity tissue in African-American and white men versus women, whereas the work done by Taaffe [32] and colleagues reported a positive association between femoral neck BMD and the fat mass in women but not in men. These contradictory results highlight the important action of the other covariates. The discrepancy between the prevalence of low trauma fracture and the bone mineral density between males and females raises the question of the optimum interventional threshold for men and whether this should be different from post-menopausal women.
One of the most interesting findings in the current study is that although the fracture risk probability assessed by FRAX calculator was significantly lower in obese patients, the effect of obesity on the incidence of fracture controlling the other factors was not significant among different BMI groups. This highlights the fact that obesity may not be protective against the occurrence of fragility fracture. Several studies investigated this debated issue. They postulated that obesity may be protective against hip fractures, but obese patients may be more at risk for distal radial, upper humeral, and ankle fractures [33, 34]. Another study conducted on Japanese postmenopausal female patients revealed that the incidence of vertebral fractures was significantly lower in underweight and normal weight females compared to overweight and obese females if BMD and other risk factors were adjusted [35]. It is worth noting that FRAX assessment may be improved if fracture sites are taken into consideration.
Results of this work underlined the principal role of obesity as an important covariate. Obesity was correlated significantly with sarcopenia and fractures. Sarcopenia is one of the conditions associated with aging [36]. Several causes have been postulated to explain sarcopenic obesity in elderly people including alteration of skeletal muscle lipid metabolism, induction of insulin resistance, and stimulation of inflammatory pathways. Both sarcopenia and obesity are cut from the same cloth where they share similar pathophysiologic factors, including lifestyle behaviors, hormonal changes, and immunological factors, all of which may synergistically increase the risk of developing a series of adverse health problems, functional waning, and consequently disability [37]. Scott and colleagues [38] reported in their study that both men and women with both obesity and sarcopenia were found to have lower-leg muscle density and lower balance, consequently at high risk of falling. These findings agree with the results of this work which revealed significantly higher falls risk in the cohort with obesity and sarcopenia. Similarly, Follis et al. [39] reported that people with obesity and sarcopenia had 1.35-folds and 1.21-folds increased fall risk in age group 50 to 64 years old and 65 to 79 years old respectively. These findings reflect the double impact of sarcopenia and obesity. Such double phenomenon highlights the importance of considering these covariates when managing older adults with sarcopenic obesity, putting in consideration the possible high risks of osteoporosis and falls.
In addition to falls risk and sarcopenia, this study highlighted the important role of physical inactivity/disability, as an important covariate in the of occurrence of fragility fractures. While most research focus on the functional decline after fragility fractures [40], less attention has been paid to physical disability as a contributing factor for fragility fractures. However, indirectly, several studies revealed elevated risk of fragility fractures in patients living with diseases such as Parkinsonism [41] and stroke [42] who are known to have significant physical disability. Bone cells and fat have a common cellular origin (the same bone marrow stem cells) [43], and both aging and low physical activity induce osteoporosis and obesity [44]. In addition, these two disorders synergistically induce functional impairments and physical disabilities [24, 45] which suggest a complex effect of obesity on bone health. These results of this work are in favor of the FRAXplus and its important role in including the important risk factors for the calculation of the individual patient’s fracture risk.
Limitations of the study
This study relied on the FRAX as a tool for the assessment of fracture risk. Given that obesity is usually associated with other comorbidities that might have an impact on bone health, this could be a limitation of the study. Assessment of the FRAXplus risk is advisable to be carried out in a future study. Additionally, obesity is suggested to affect bone quality rather than bone mass; thus, it would be more reasonable to study the impact of obesity on altered bone microarchitecture by assessing the trabecular bone score that predicts fractures independently of other clinical risk factors and BMD [46].
Conclusion
In conclusion, progressive aging and increasing life expectancy of the population translates into a higher prevalence of diseases and disorders associated with old age. Obesity was found to be associated with BMD of the hip and lumbar spine as well as distal forearm. Similarly, overweight and obese individuals had similar degrees of osteoporosis. There was a statistically significant difference in post-menopausal women but not in men. Covariates such as sarcopenia, falls risk, and functional disability play an important factor in making the patient at high risk of developing a low impact fracture.
Availability of data and materials
The data will be available upon reasonable request.
Abbreviations
- BMD:
-
Bone mineral density
- BMI:
-
Body mass index
- DXA:
-
Dual energy X-ray absorptiometry
- FLS:
-
Fracture liaison service
- FRAS:
-
Falling risk assessment score
- FRAX:
-
Fracture risk assessment
- HAQ:
-
Health Assessment Questionnaire
References
World Health Organization, Ageing and Health. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health Accessed 15 June 2023.
Beard JR, Officer A, de Carvalho IA, Sadana R, Pot AM, Michel JP et al (2016) The world report on ageing and health: a policy framework for healthy ageing. Lancet 387:2145–2154
Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O’Donnell M, Sullivan R et al (2015) The burden of disease in older people and implications for health policy and practice. Lancet 385:549–562
Jura M, Kozak LP (2016) Obesity and related consequences to ageing. Age (Dordr) 38(1):23. https://doi.org/10.1007/s11357-016-9884-3
Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA (1999) Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet (London, England) 353(9156):878–882. https://doi.org/10.1016/S0140-6736(98)09075-8
Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR (2009) Mortality risk associated with low trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301(5):513–521. https://doi.org/10.1001/jama.2009.50
Morin S, Lix LM, Azimaee M, Metge C, Caetano P, Leslie WD (2011) Mortality rates after incident non-traumatic fractures in older men and women. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 22(9):2439–2448. https://doi.org/10.1007/s00198-010-1480-2
Melton LJ 3rd (2003) Adverse outcomes of osteoporotic fractures in the general population. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 18(6):1139–1141. https://doi.org/10.1359/jbmr.2003.18.6.1139
Rubin CT, Lanyon LE (1984) Regulation of bone formation by applied dynamic loads. J Bone Joint Surg Am 66:397–402
Edelstein SL, Barrett-Connor E (1993) Relation between body size and bone mineral density in elderly men and women. Am J Epidemiol 138:160–169
Felson DT, Zhang Y, Hannan MT, Anderson JJ (1993) Effects of weight and body mass index on bone mineral density in men and women: the Framingham study. J Bone Miner Res 8:567–573
Gonnelli S, Caffarelli C, Nuti R (2014) Obesity and fracture risk. Clin Cases Miner Bone Metab 11:9–14
Kaze AD, Rosen HN, Paik JM (2018) A meta-analysis of the association between body mass index and risk of vertebral fracture. Osteoporos Int 29:31–39
Nielson CM, Srikanth P, Orwoll ES (2012) Obesity and fracture in men and women: an epidemiologic perspective. J Bone Mineral Research 27(1):1–10
De Laet C, Kanis JA, Oden A, Johanson H, Johnell O, Delmas P et al (2005) Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 16(11):1330–1338. https://doi.org/10.1007/s00198-005-1863-y
Gadallah N, El Miedany Y (2022) Operative secondary prevention of fragility fractures: national clinical standards for fracture liaison service in Egypt—an initiative by the Egyptian Academy of Bone Health. Egypt Rheumatol Rehabil 49:11. https://doi.org/10.1186/s43166-022-00111-7
El Miedany Y, El Gaafary M, Toth M, Palmer D, Ahmed I (2011) Falls risk assessment score (FRAS): time to rethink. J Clin Gerontology and Geriatrics 2(1):21–26
Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE (2016) SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle 7(1):28–36. https://doi.org/10.1002/jcsm.12048
El Miedany Y, El Gaafary M, Ahmed I (2003) Cross-cultural adaptation and validation of an Arabic Health Assessment Questionnaire for use in rheumatoid arthritis patients. Joint Bone Spine 70(3):195–202
Cui LH, Shin MH, Kweon SS, Park KS, Lee YH, Chung EK et al (2007) Relative contribution of body composition to bone mineral density at different sites in men and women of South Korea. J Bone Miner Metab 25:165–171
Lekamwasam S, Weerarathna T, Rodrigo M, Arachchi WK, Munidasa D (2009) Association between bone mineral density, lean mass, and fat mass among healthy middle-aged premenopausal women: a cross-sectional study in southern Sri Lanka. J Bone Miner Metab 27:83–88
Salamat MR, Salamat AH, Abedi I, Janghorbani M (2013) Relationship between weight, body mass index, and bone mineral density in men referred for dual-energy X-ray absorptiometry scan in Isfahan. Iran J Osteoporos 2013:205963
Salamat MR, Salamat AH, Janghorbani M (2016) Association between obesity and bone mineral density by gender and menopausal status. Endocrinol Metab (Seoul) 4:547–558. https://doi.org/10.3803/EnM.2016.31.4.547
Taes YE, Lapauw B, Vanbillemont G, Bogaert V, De Bacquer D, Zmierczak H et al (2009) Fat mass is negatively associated with cortical bone size in young healthy male siblings. J Clin Endocrinol Metab 94:2325–2331
Zhao LJ, Liu YJ, Liu PY, Hamilton J, Recker RR, Deng HW (2007) Relationship of obesity with osteoporosis. J Clin Endocrinol Metab 92:1640–1646
Janicka A, Wren TA, Sanchez MM, Dorey F, Kim PS, Mittelman SD et al (2007) Fat mass is not beneficial to bone in adolescents and young adults. J Clin Endocrinol Metab 92:143–147
Chang CS, Chang YF, Wang MW, Chen CY, Chao YJ, Chang HJ et al (2013) Inverse relationship between central obesity and osteoporosis in osteoporotic drug naive elderly females: the Tianliao Old People (TOP) Study. J Clin Densitom 16:204–211
Stenholm S, Harris TB, Rantanen T, Visser M, Kritchevsky SB, Ferrucci L (2008) Sarcopenic obesity: definition, cause and consequences. Curr Opin Clin Nutr Metab Care 11:693–700
Ley CJ, Lees B, Stevenson JC (1992) Sex- and menopause-associated changes in body-fat distribution. Am J Clin Nutr 55:950–954
Katzmarzyk PT, Barreira TV, Harrington DM, Staiano AE, Heymsfield SB, Gimble JM (2012) Relationship between abdominal fat and bone mineral density in white and African American adults. Bone 50:576–579
Taaffe DR, Cauley JA, Danielson M, Nevitt MC, Lang TF, Bauer DC et al (2001) Race and sex effects on the association between muscle strength, soft tissue, and bone mineral density in healthy elders: the Health, Aging, and Body Composition Study. J Bone Miner Res 16:1343–1352
Compston JE, Watts NB, Chapurlat R, Cooper C, Boonen S, Greenspan S et al (2011) Obesity is not protective against fracture in postmenopausal women: GLOW. Am J Med 124:1043–1050. https://doi.org/10.1016/j.amjmed.2011.06.013
Prieto-Alhambra D, Premaor MO, Avilés F, Fina HE, Martinez-Laguna D, Carbonell-Abella C et al (2012) The association between fracture and obesity is site-dependent: a population-based study in postmenopausal women. J Bone Min Res 27:294–300. https://doi.org/10.1002/jbmr.1466
Tanaka S, Kuroda T, Saito M, Shiraki M (2013) Overweight, obesity and underweight are both risk factors for osteoporotic fractures at different sites in Japanese postmenopausal women. Osteoporos Int 24(1):69–76. https://doi.org/10.1007/s00198-012-2209-1. Epub 2012 Nov 15. Erratum in: Osteoporos Int. 2013 Mar;24(3):1143-4. PMID: 23229467
Cruz-Jentoft AJ, Sayer AA (2019) Sarcopenia Lancet 393:2636–2646. https://doi.org/10.1016/S0140-6736(19)31138-9
Roh E, Choi KM (2020) Health consequences of sarcopenic obesity: a narrative review. Front Endocrinol (Lausanne) 11:332. https://doi.org/10.3389/fendo.2020.00332
Scott D, Shore-Lorenti C, McMillan L, Mesinovic J, Clark RA et al (2018) Associations of components of sarcopenic obesity with bone health and balance in older adults. Arch Gerontol Geriatr 75:125–131
Follis S, Cook A, Bea JW, Going SB, Laddu D et al (2018) Association between sarcopenic obesity and falls in a multiethnic cohort of postmenopausal women. J Am Geriatr Soc 66:2314–2320
Dyer SM, Crotty M, Fairhall N et al (2016) A critical review of the long-term disability outcomes following hip fracture. BMC Geriatr 16:158. https://doi.org/10.1186/s12877-016-0332-0
Torsney KM, Noyce AJ, Doherty KM et al (2014) Bone health in Parkinson’s disease: a systematic review and meta-analysis. J Neurology, Neurosurgery & Psychiatry 85:1159–1166
Poole KE, Reeve J, Warburton EA (2002) Falls, fractures, and osteoporosis after stroke: time to think about protection? Stroke 33(5):1432–1436. https://doi.org/10.1161/01.str.0000014510.48897.7d
Rosen CJ, Klibanski A (2009) Bone, fat, and body composition: evolving concepts in the pathogenesis of osteoporosis. Am J Med 122:409–414
Kim CJ, Oh KW, Rhee EJ, Kim KH, Jo SK, Jung CH et al (2009) Relationship between body composition and bone mineral density (BMD) in perimenopausal Korean women. Clin Endocrinol (Oxf) 71:18–26
Yamaguchi T, Kanazawa I, Yamamoto M, Kurioka S, Yamauchi M, Yano S et al (2009) Associations between components of the metabolic syndrome versus bone mineral density and vertebral fractures in patients with type 2 diabetes. Bone 45:174–179
Shevroja E, Cafarelli FP, Guglielmi G, Hans D (2021) DXA parameters, trabecular bone score (TBS) and bone mineral density (BMD), in fracture risk prediction in endocrine-mediated secondary osteoporosis. Endocrine. 74(1):20–28.https://doi.org/10.1007/s12020-021-02806-x. Epub 2021 . PMID: 34245432; PMCID: PMC8440280
Duplicate publication
This is to confirm that the content of the manuscript has not been published or submitted for publication elsewhere.
Mini abstract
This work studies the relationship between the triad of obesity, fracture risk factors, and osteoporosis and its impact on fragility fractures. While obesity was found to be associated with higher BMD of the hip and lumbar spine as well as distal forearm, there was no significant difference on comparing the fragility of fractures.
Author information
Authors and Affiliations
Contributions
All authors contributed to the study methodology, analysis, and interpretation of the data and outcomes as well as the manuscript writing, reading, and approval of the final version.
Corresponding author
Ethics declarations
Ethics approval and consent to participate
This study is in agreement with the ethical guidelines of the Declaration of Helsinki, and it follows the ethical standards of Alexandria Faculty of Medicine, IRB NO: 00012098. An informed written consent was obtained from all patients in accordance with the local ethical committee. Privacy of all patients’ data was granted as there was a code number for every patient file that included all investigations.
Consent for publication
Not applicable.
Competing interests
The authors declare that Mohammed H Abu-Zaid is an associate editor in the Egyptian Rheumatology and Rehabilitation. Waleed Hassan, Safaa Mahran, Naglaa GadAllah, and Yasser El Miedany are from the editorial board of the journal.
Additional information
Publisher’ s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
El Miedany, Y., El Gaafary, M., Mahran, S. et al. The inter-relationship of the triad: osteoporosis, fracture risk, and obesity—a longitudinal multicenter analysis by the Egyptian Academy of Bone Health. Egypt Rheumatol Rehabil 51, 7 (2024). https://doi.org/10.1186/s43166-024-00241-0
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s43166-024-00241-0