Archives of Biochemistry and Biophysics 503 (2010) 20–27

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Archives of Biochemistry and Biophysics

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Review

Fat and bone q

Ian R. Reid *
Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: Body weight is a principal determinant of bone density and fracture risk, and adipose tissue mass is a
Available online 3 July 2010 major contributor to this relationship. In contrast, some recent studies have argued that ‘‘fat mass after
adjustment for body weight” actually has a deleterious effect on bone, but these analyses are confounded
Keywords: by the co-linearity between the variables studied, and therefore have produced misleading results. Mech-
Body composition anistically, fat and bone are linked by a multitude of pathways, which ultimately serve the function of
Lean mass providing a skeleton appropriate to the mass of adipose tissue it is carrying. Adiponectin, insulin/amy-
Osteoporosis
lin/preptin, leptin and adipocytic estrogens are all likely to be involved in this connection. In the clinic,
Insulin
Leptin
the key issues are that obesity is protective against osteoporosis, but underweight is a major preventable
Amylin risk factor for fractures.
Ó 2010 Elsevier Inc. All rights reserved.

Introduction
A consideration of the relationships between adipose tissue and
the skeleton involves two quite different sets of data. The first is
epidemiological evidence which relates measures of adiposity to
measures of skeletal mass/density and facture risk. The second is
a consideration of the physiological mechanisms that lead to these
relationships. Each of these aspects of this subject will be consid-
ered in turn.
Epidemiology
Fat mass and bone density
The relationship between fat mass and bone density emerged
from clinical studies carried out in the early 1990s [1–3]. Dual-en-
ergy X-ray absorptiometry (DXA)1 had just become available for
measurement of axial bone density, and these devices could also
assess fat mass and lean mass. Thus, a number of groups undertook
studies of the relationships between soft tissue mass and bone
density, and found consistently positive relationships, though
studies varied according to whether fat mass or lean mass showed
the strongest correlation with bone density (reviewed in detail
elsewhere [4,5]). Most studies have assessed only total fat mass,
q
Supported by the Health Research Council of New Zealand.
* Fax: +64 9 308 2308.
E-mail address: i.reid@auckland.ac.nz
1
Abbreviations used: DXA, Dual-energy X-ray absorptiometry; BMD, bone mineral
density; BMI, body mass index; GLP-1, glucagon-like peptide-1; GIP, glucose-
dependent insulinotropic polypeptide.
but Gilsanz has recently suggested that it is subcutaneous fat that
is beneficial to bone, and that visceral fat is deleterious [6]. There
have now been a large number of essentially similar studies look-
ing at relationships between fat mass and bone density, with an
increasing variety of outcomes. Most of that variability in out-
comes is attributable to the use of diverse methods for measuring
bone density and, most importantly, to differences in the methods
of statistical analysis.
When assessing relationships between fat mass and bone, it
must be remembered that bone mineral content, areal bone den-
sity and volumetric bone density are not interchangeable. Bone
mineral content and areal bone density are both dependent, to dif-
ferent degrees, on skeletal size, so will correlate with any other
variable (such as lean mass) which is also dependent on skeletal
size. DXA measures areal bone density (in g/cm2) so is also influ-
enced by bone size, as well as the material density of the bone
being assessed. Failure to appreciate this fact will lead to the
description of spurious relationships, with inappropriate infer-
ences of causality.
The statistical problems relate to inappropriately treating
highly inter-correlated variables as being independent. A particular
example of this is correcting variables, such as fat mass, for others,
such as weight, to which they are closely related. I will use a well-
described cohort of healthy postmenopausal women from the
Auckland Calcium Study [7] to illustrate the relationships between
soft tissue mass and bone density, and the results of incautious
analyses of these variables.
Auckland Calcium Study
Fig. 1 shows some of the relevant relationships from this study.
In Fig. 1a, we see a direct linear relationship between body weight

0003-9861/$ - see front matter Ó 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.abb.2010.06.027
 I.R. Reid / Archives of Biochemistry and Biophysics 503 (2010) 20–27 21

Fig. 1. Regression relationships between total hip bone mineral density (g/cm2) and indices of soft tissue mass in 1462 normal postmenopausal women from the Auckland
Calcium Study. ‘‘r” is the Pearson correlation coefficient. Copyright Reid, used with permission.

and total hip bone mineral density (BMD), similar to what has been
seen in many studies previously. In trying to deduce whether this
is primarily a relationship with fat mass or with lean mass, body
mass index (BMI) can be substituted for weight. BMI is commonly
used as a surrogate for adiposity (see Table 1), and we see almost
the same relationship between this variable and bone density as
we saw with weight. However, using DXA it is possible to measure
total body fat mass and total body lean mass separately, and these
two plots are shown in panels c and d of Fig. 1. Their relationship to
BMD is not quite as close as that of weight or BMI, but the correla-
tion coefficients are comparable to one another. However, fat mass
and lean mass are related to one another (see Table 1) so it is pos-
sible that the relationships shown in these panels are contributed
to by co-linearity between fat and lean masses. Multiple regression
analysis potentially provides a way of dissecting these relation-
ships. Using this technique, with total hip BMD as the dependent
variable and fat mass and lean mass as the independent variables,
we find that both are positively related to BMD (p < 0.0001), but
that fat mass has a partial R2 value of 0.09, whereas that for lean
mass is 0.03, implying that fat mass accounts for three times more
of the variance than does lean mass. Formal statistical tests for the
influence of multi co-linearity (calculating the variance inflation
22 I.R. Reid / Archives of Biochemistry and Biophysics 503 (2010) 20–27

Table 1 puberty in boys is associated with bone gain, loss of fat mass, and
Correlations between soft tissue indices and BMD in the Auckland Calcium Study. gain in muscle mass. Therefore, men, premenopausal women, and
Lean Fat Weight % Fat % Lean BMI L1-4 postmenopausal women are quite distinct populations with re-
mass mass mass mass BMD spect to their bone densities, soft tissue masses, and the regulation
Fat mass 0.37 of these variables, so should not be combined together in the same
Weight 0.65 0.92 cross-sectional analysis. Regression analysis assumes normal dis-
% Fat 0.07a 0.92 0.72 tributions of all the variables being studied and the lumping to-
mass
% Lean 0.02b 0.85 0.73 0.91
gether of such disparate populations violates these assumptions
mass and is likely to produce results which are quite different from those
BMI 0.42 0.91 0.90 0.79 0.80 which would emerge from the analysis of individual homogeneous
L1-4 BMD 0.28 0.25 0.35 0.15 0.19 0.30 populations on their own.
Total hip 0.28 0.30 0.41 0.20 0.30 0.39 0.58
BMD
Soft tissue and bone relationships during growth
All other correlations are significant, p < 0.0001. As mentioned above, some parameters of bone density are di-
a
p = 0.07.
b
rectly related to skeletal size. This becomes a particular problem
p = 0.01.
when dealing with children, in whom a wide range of skeletal sizes
will often be studied in the same cohort. This problem is made all
factor) indicate that these analyses are sound. Another way of the more acute by the preference of many pediatric bone research-
assessing the relative importance of fat and lean masses without ers to use bone mineral content as the index of bone density. This is
depending upon the complexities and potential pitfalls of multiple very closely related to skeletal size, as is total lean mass. Therefore,
regression analysis, is to simply relate BMD to either fat mass or many of these studies are simply saying that large children have
lean mass as a percent of body weight, and this is shown in panels more muscle and more bone, and this is not telling very much
e and f of Fig. 1. It can be seen that BMD is positively related to per- about the regulation of bone density. The use of experimental de-
cent fat and, therefore, inversely related to percent lean, since signs which allow separation of effects on linear growth from those
these two variables are the converse of one another. on bone density would allow greater insight into optimization of
Some authors have then attempted to use multiple regression these two potentially independent contributors to pediatric skele-
analysis to ask how fat mass is related to BMD after correction tal health.
for body weight. This involves entering both fat mass and body It should not be assumed that the relationships between soft
weight into the same multiple regression analysis, and Table 1 tissue and bone are necessarily the same during growth as they
shows that this is not likely to yield valid results because of the are in adult life, since the biological processes involved are quite
substantial co-linearity between these variables. Indeed, when different. Indeed, the influence of fat mass on BMD appears to be
body weight is added to the multiple regression analysis of fat greater in older rather than younger women [3,8,9] which would
and lean mass as referred to above, then the diagnostic tests car- be consistent with fat mass exerting an influence on bone turnover
ried out as part of that analysis indicate that co-linearity invali- throughout the adult years different from the effect it has during
dates the result. If we ignore this caution, the following equation adolescence, when most of adult bone mass is laid down.
results: Studies of children are also complicated by the advent of pub-
erty which has a positive effect on bone density in both sexes,
BMD ¼ 0:4 þ 0:02  Weight  0:01  Fat  0:01  Lean but in boys is associated with loss of fat mass. Studies which mix
boys and girls, and individuals at different states of pubertal devel-
This indicates that both fat mass and lean mass are now inver-
opment could result in quite unstable results. Again, homogeneity
sely related to bone density while weight is positively related to
of the cohorts assessed is likely to be an important consideration in
BMD. Weight is the dominant variable in this regression (partial
producing biologically meaningful results.
R2 is 0.17 in comparison with 0.04 for fat mass and 0.03 for lean
mass). Interpreted literally, this would indicate that increases in
Animal studies
either lean or fat mass will have a detrimental effect on bone den-
The above considerations relate to clinical studies. There are
sity whereas increases in body weight will have beneficial effects.
now a large number of animal models used to study relationships
This is obviously nonsense and results from inappropriate use of
between bone and adipose tissue, and these carry with them a sim-
statistics. It is a sad reflection on the current state of journal
ilar set of problems. There is a diversity of bone mass/density
reviewing, that a number of papers making this error have been
assessment techniques used in animal studies, including histomor-
published in recent times. It has resulted in statements that obesity
phometry, quantitative computed tomography and DXA scanning.
is a risk factor for osteoporosis, whereas properly analyzed studies
These techniques can be applied to axial trabecular bone or to
show quite the opposite, as does the epidemiology of fractures (see
appendicular cortical bone. Many of the contradictions in the ani-
below). Similar issues may arise with studies of factors released
mal studies of leptin and bone, for instance, can be traced back to
from adipocytes (e.g. leptin) when these are included as ‘indepen-
these differences. Thus, an animal with reduced long bone growth
dent’ variables along with fat mass itself. Interpretation of such
will have reduced total body bone mineral content but can still
analyses requires great care if these analyses are not to be
have increased trabecular bone volume in the vertebral body.
misleading.
The studies of leptin effects on bone in animals suggest quite dif-
ferent effects on the different skeletal envelopes, in a way that does
Other methodological issues not appear to occur in humans. Therefore, the relevance of these
A further issue which needs to be considered in cross-sectional findings to human physiology can be questioned. It should be
studies of bone and soft tissue, is the effect of pooling disparate remembered that mice and rats do not show haversian remodeling
groups, such as men and women, or pre- and postmenopausal wo- of cortical bone in the way that humans do. Thus, studies in these
men. Sex hormones have profound effects on bone, but they also species are essentially of growing bone and may not be relevant to
influence and are influenced by soft tissue composition. For in- what is seen in the remodeling bone of adult humans. Finally, it is
stance, the menopausal transition is associated with substantial possible to subject animals to completely non-physiological inter-
bone loss, but gain in fat mass. Conversely, the transition through ventions, such as treatment with supra-physiological doses of
 I.R. Reid / Archives of Biochemistry and Biophysics 503 (2010) 20–27
drugs, selective targeting of regulatory compounds to a single tar-
get organ (e.g. leptin administration to the brain), or selective or
generalized knockout of a regulatory factor. Each of these may give
vital insights into physiological mechanisms, but interpretation of
such studies must always consider how close the experimental
intervention is to the physiological situation that obtains in hu-
mans, in order to determine its applicability to human physiology.
Fat mass and fractures
One of the most consistent findings from epidemiological stud-
ies is that low body weight is a risk factor for fracture. This has now
been confirmed in a meta-analysis of 60,000 men and women from
12 prospective, population-based cohorts, which showed that total
fractures, osteoporotic fractures and hip fractures are all inversely
related to BMI in both men and women [10] (Fig. 2). When these
results are adjusted for BMD, the relationship is lost for total frac-
tures and osteoporotic fractures, suggesting that the effect of BMI
is mediated through its effect on BMD. However, for hip fracture
there is still a residual protective effect from high BMI even after
adjustment for BMD. Possibly, it is the shock-absorbing effect of
adipose tissue over the greater trochanter that provides this extra
fracture protection at the hip.
Other studies have related fracture risk to fat and lean masses
directly. In the Study of Osteoporotic Fractures, both lean mass
and fat mass (assessed using bioelectrical impedance) were shown
to be related to hip fracture risk [11]. In a large French epidemio-
logical study there was a 40% increase in hip fracture risk for each
standard deviation decrease in fat mass, but no effect of lean mass
[12]. Similarly, in a study of Chinese men in Hong Kong, the odds
ratio for vertebral fracture was 7.0 when the first quartile of fat
mass was compared with the fourth quartile, whereas comparisons
of the same quartiles for lean mass produced a non-significant
odds ratio of 2.2 [13]. Thus, there is unequivocal evidence that
BMI is related to fracture risk, and as Table 1 demonstrates, BMI
is closely related to fat mass and percent fat mass, so is a valid
measure of adiposity. While studies relating fat mass to fracture
risk are smaller and less numerous, their results are consistent
with the notion that adiposity is protective against fracture.
When considering fracture epidemiology in relation to soft tis-
sue mass in children, it is important to remember that children suf-
fer predominantly forearm fractures, and that the risk factors for
such fractures in adults are not the same as those for other frac-
tures. Thus, increased body weight has been found to be less pro-
tective for forearm than for hip or vertebral fractures in adult
cohorts [14,15].
Fig. 2. Meta-analysis of the effect of body mass index on fracture risk, with and without adjustment for bone mineral density. From De Laet et al. [10], used with permission.
23
Mechanisms
The array of pathways linking adipose tissue with bone is
becoming steadily more complex, and there is even evidence
now that the relationships may operate in both directions. The fac-
tors mediating these relationships can be classified in a variety of
ways. Some factors, such as those secreted from the adipocyte or
the pancreatic beta cell, are directly influenced by fat mass. Some
of these factors, and a number of others, are influenced acutely
by food ingestion. Over time, both of these influences are likely
to impact on bone mass.
Bone-active hormones influenced by adiposity
Adipokines
Leptin is the adipokine that has been most studied in relation to
bone. The signaling form of the leptin receptor has been shown to
be expressed in both osteoblasts and chondrocytes [16,17]. Leptin
increases proliferation and differentiation of osteoblasts [17–19]
and promotes bone nodule formation [20,21]. It also increases
chondrocyte growth [17,22], accounting for the short limbs of ani-
mals with impaired leptin signaling. Leptin also regulates osteo-
clast development [17,23], at least in part through changes in
production of RANK, RANK-ligand, and osteoprotegerin [23,24].
Thus its combined effects on bone formation and resorption in-
crease skeletal mass so that obese individuals will achieve the
stronger skeleton needed to support their greater soft tissue mass.
Leptin also has the potential to affect bone through its actions
on the central nervous system. Infusion of leptin into the third ven-
tricle causes bone loss in leptin-deficient and wild-type mice
through inhibition of bone formation [25] and stimulation of bone
resorption [26]. Blockade of the sympathetic nervous system abro-
gates these effects, which appear to be mediated by b-adrenore-
ceptors on osteoblasts [27]. These effects will interact with the
direct effects already described, and the balance of direct and indi-
rect effects is likely to differ in different physiological and experi-
mental situations. Because leptin is produced in bone marrow
adipocytes, chondrocytes and cells of the osteoblast lineage [28],
its local effects on bone might be expected to be dominant. Also,
when it is administered centrally, it leads to a dramatic reduction
in appetite with profound weight loss, resulting in reduced serum
levels of leptin, and increases in ghrelin [29–31]. Thus, much of the
bone loss observed with central administration of leptin might
simply reflect the profoundly catabolic state of these animals, a
suggestion supported by the finding that bone loss can be pro-
duced by caloric restriction alone [32]. Both central administration
of leptin and weight loss cause reductions in circulating levels of
24 I.R. Reid / Archives of Biochemistry and Biophysics 503 (2010) 20–27
insulin, which will also have secondary effects on bone. The poten-
tial interactions of these effects are depicted in Fig. 3. Sympathetic
nervous system effects on bone are well recognized but may be rel-
atively unimportant in most contexts, since b-adrenergic blockade
does not consistently influence bone density, rates of bone loss, or
fracture [33]. In a prospective randomized controlled trial in nor-
mal women, we did not find that propranolol stimulated bone for-
mation [34], as would have been expected if sympathetic tone was
an important regulator of this function in human physiology.
Studies of leptin deficiency and systemic leptin administration
in animals support these general conclusions. Leptin deficiency is
associated with reduced linear growth, reduced cortical bone mass,
increased trabecular bone of the spine but reduced trabecular bone
in the femora, where huge adipocytes occupy much of the marrow
space [35]. Systemic administration of leptin in animals (intact or
leptin-deficient) usually results in an improvement in bone forma-
tion, skeletal mass or strength [16,17,24,36,37]. In leptin-deficient
animals, leptin replacement reverses the adipocyte phenotype and
increases total body bone mineral content by >30% [36]. However,
systemic administration of high doses of leptin may have negative
effects on bone, similar to its central administration [38], because
these doses are associated with weight loss and decreases in serum
IGF1 levels.
Assessments of the effects of leptin administration in humans
are scanty. Farooqi et al. [39] provided leptin replacement to a 9-
year old leptin-deficient girl, and observed weight loss accompa-
nied by bone gain. Welt et al treated eight women suffering from
hypothalamic amenorrhea with leptin for up to three months. Thus
resulted in increases in estradiol, thyroid hormones, IGF1, insulin-
like growth factor-binding protein-3, bone alkaline phosphatase,
and osteocalcin, demonstrating the many indirect mechanisms
by which this hormone can impact on the skeleton [40]. Both these
studies indicate that the skeletal effects of systemic leptin in hu-
mans are positive. Ultimately, this dominance is attested to by
the consistent positive relationship between fat mass and bone
density – if the central effects of leptin were dominant, there
would be an inverse relationship.
Adiponectin is now emerging as a very important adipokine
which circulates in much higher concentrations than other adipo-
cyte products, in the range 0.5–30 lg/mL [41]. It is a 28 kD protein
with close homology to compliment factor C1q and collagens VIII
and X [42], and circulates as trimers, hexamers and high-molecular
weight oligomers [43,44]. Plasma concentrations of adiponectin
are inversely related to visceral fat mass and BMI [41]. Adiponectin
regulates energy homeostasis, glucose and lipid metabolism and
ICV Leptin
via SNS
Satiety
↓ Insulin Resistance
Weight Loss
↓ Peripheral Leptin ↓ Peripheral Insulin, Amylin, Preptin
↓Osteoblast Activity
↑ Osteoclast Activity
↓Bone Mass
Fig. 3. Possible mechanisms for central leptin effects on bone, via reduced
peripheral insulin and leptin levels. SNS = sympathetic nervous system. Copyright
Reid, used with permission.
inflammatory pathways [45]. Serum adiponectin levels correlate
with insulin sensitivity [46–48], low levels being found in subjects
with coronary artery disease and type 2 diabetes mellitus [49,50].
There is a small but contradictory literature regarding adipo-
nectin’s effects on bone in laboratory studies. The receptors for
adiponectin, AdipoR1 and AdipoR2, have been identified on both
osteoblasts and osteoclasts [51,52], and it increases osteoblast pro-
liferation and differentiation while inhibiting osteoclastogenesis
in vitro [53–55]. Thus, adiponectin would be expected to increase
in bone mass in vivo but studies in transgenic mice have been
inconsistent [51,53]. However, in 14-week old adiponectin-knock-
out mice, trabecular bone volume is increased by 30% [56] suggest-
ing that indirect effects are more powerful than direct effects of
this adipokine on bone. These indirect effects might include mod-
ulation of insulin sensitivity and growth factor binding. The magni-
tude of the bone changes in the knockout mice indicates that
adiponectin is likely to be a significant contributor to the fat–bone
relationship. This is supported by clinical studies which show con-
sistent inverse relationships between circulating adiponectin con-
centrations and BMD [57–59].
Resistin modestly increases the proliferation of osteoblasts in
both cell and organ culture systems and increases the formation
and activity of osteoclasts [60,61]. Whether these counter-balanc-
ing effects lead to any change in bone mass is not known. The adi-
pocyte has long been recognized as an estrogen-producing cell,
particularly in postmenopausal women. Thus, early postmeno-
pausal women who lose bone rapidly have lower levels of both es-
trone and estradiol than ‘‘slow losers”, and this may be contributed
to by their lower fat mass [62]. Our own work has confirmed a rela-
tionship between circulating estrone levels and bone density, but
has shown this to be both independent of the effects of fat mass
and substantially weaker [8]. This implies that estrogen is not
the only pathway by which fat influences bone density, a sugges-
tion supported by the finding of a fat–bone relationship in pre-
menopausal women, in whom the adipocyte is a relatively minor
source of estrogens.
As noted above, there is some evidence that subcutaneous and
visceral fat have different associations with bone mass. The reasons
for this are uncertain but there is evidence that secretion of adipo-
nectin and leptin is less from visceral adipocytes, and that aroma-
tase activity (and therefore estrogen production) is also lower [6].
In contrast, the bone resorbing cytokines TNFa_and IL-6 circulate
in higher concentrations in subjects with visceral adiposity [63].
The products of visceral adipocytes can also directly impact on
the liver via the portal circulation, which might also contribute
to their differential effects on bone metabolism.
Beta cell hormones
Insulin, and the factors co-secreted with it, amylin and preptin,
circulate in increased concentrations in obesity. These peptides are
directly stimulatory to osteoblast growth, and amylin also has a
potent calcitonin-like effect, inhibiting osteoclastic bone resorp-
tion. Insulin may also increase bone density indirectly. Hyperinsu-
linemic women display increased androgen and estrogen
production in the ovary, and insulin directly inhibits production
of sex hormone binding globulin in the liver. Thus, insulin in-
creases free concentrations of both androgens and estrogens,
which will increase bone mass. Hyperinsulinemia is also associated
with increased circulating levels of saturated fatty acids, which are
able to directly inhibit osteoclastogenesis [64]. The interaction of
these activities is shown in Fig. 4. As a result, high bone density
is a very consistent finding across a wide range of hyperinsuline-
mic states, including obesity, polycystic ovary syndrome [65] and
congenital generalized lipodystrophy [66]. The latter is particularly
significant because it represents a dissociation of fat mass and
insulin levels. These findings are consistent with the literature
 I.R. Reid / Archives of Biochemistry and Biophysics 503 (2010) 20–27
Fat Mass
Insulin Resistance
β−Cell Hypersecretion
insulin preptin
SHBG Ovarian E production
Free sex hormones
Fig. 4. Summary of the principal mechanisms by which the hyperinsulinemia associated with obesity contributes to increased bone mass. An additional mechanism, not
shown, is via increases in free fatty acid levels resulting from hyperinsulinemia which inhibit osteoclastogenesis. Copyright Reid, used with permission.
showing lower bone densities in insulinopenic diabetes and in-
creased facture risk in these subjects [67].
In clinical studies, circulating insulin levels, both fasting and fol-
lowing a glucose load, are related to bone density. We have show
this in normal postmenopausal women and found the effect to
be partly independent from that of adiposity [68]. Similar effects
have been demonstrated in both men and women in the Rotterdam
study, again partly independent of BMI [69]. The San Antonio Heart
Study has produced comparable findings in women [70]. Abraham-
sen et al. [71] studied these relationships in men, and found that
insulin sensitivity (measured from an intravenous glucose toler-
ance test) was inversely related to bone density independently of
weight and fat mass. In addition, they found that the dependence
of bone density on fat mass was lost when insulin sensitivity was
entered into the multiple regression analysis, suggesting that this
relationship was mediated through insulin sensitivity. Recently,
the Tromso study has found that non-vertebral fracture risk pro-
gressively declines with increasing insulin resistance (inferred
from the severity of the metabolic syndrome), being reduced by
50% in those with greatest insulin resistance [72].
Integration of effects of fat mass and hormones
In the 20 years since the inter-dependence of fat mass and bone
mass became apparent, many factors that might mediate the con-
nection have been identified. The problem has now become to
determine the relative importance of these factors and the interre-
lationships between them. In order to partially address this ques-
tion, we have recently accessed a large database of non-diabetic
women which assessed body composition and serum levels of lep-
tin, adiponectin and insulin [73,74].
In premenopausal women, bone density was consistently, pos-
itively related to fat mass, lean mass and serum leptin, and inver-
sely related to serum adiponectin. The correlations with insulin
tended to be positive but were only significant at the hip. The
osteoblast marker, osteocalcin, was inversely related to fat mass
and to leptin, but deoxypyridinoline, a marker of bone resorption,
was only significantly related (inversely) to adiponectin. Stepwise
25
amylin
Osteoblast activity Osteoclast activity
Bone Mass
multiple regression to determine which variables were the princi-
pal determinants of bone density, showed variability from one
skeletal site to another. Lean mass was consistently positively re-
lated to BMD but fat mass, leptin, adiponectin and insulin were
present variably and, to some extent, interchangeably, as a second
independent determinant of BMD (Table 2). One possible reason
for the consistent presence of lean mass in all these equations is
that there were no other closely related variables in the database
to compete with it.
In postmenopausal women, soft tissue correlations with BMD
were similar. However, the inverse relationship between adiponec-
tin and BMD was much stronger and more consistent. Osteocalcin
was again inversely related to fat mass, but also positively related
to adiponectin. The stepwise regression analysis in postmeno-
pausal women showed adiponectin and lean mass to be the princi-
pal players. The ability of adiponectin to displace the other fat-
related variables in postmenopausal women, is in marked contrast
to what is seen in premenopausal women. The bone turnover indi-
ces (osteocalcin and DPD) were related to both adiponectin and fat
mass, though lean mass, as in the premenopausal women, had no
influence on either.
This dataset confirms the important effects of fat and lean
masses on BMD in both pre- and postmenopausal women. How-
ever, it shows an even balance of the effects of the various fat-re-
Table 2
Determinants of BMD and serum osteocalcin in normal women.
Premenopausal Postmenopausal
BMD Lean Lean
Fat/insulin/adiponectin () Adiponectin ()
Osteocalcin Leptin () Fat ()
Adiponectin
Summary of results from stepwise multiple regression in 453 premenopausal
women and 215 postmenopausal women examining the dependence of BMD at
various sites and serum osteocalcin on soft tissue-related variables. () indicates an
inverse relationship, and ‘‘/” indicates that these variables were interchangeable in
the regression (see Ref. [73] for original data).
26 I.R. Reid / Archives of Biochemistry and Biophysics 503 (2010) 20–27
lated variables in premenopausal women whereas there is a domi-
nance of adiponectin in postmenopausal women. This implies an
interaction between estrogen and adiponectin. Whether the rela-
tionships between BMD and adiponectin in postmenopausal wo-
men represent direct effects of adiponectin on bone, or whether
adiponectin is simply acting as a surrogate for a cluster of fat-re-
lated effects is unknown. Relevant to this, is the recent suggestion
that adiponectin levels may reflect the biological effects of ambient
insulin levels [74].
With respect to the bone marker data, it is important to note
that turnover is influenced by fat-related variables in both pre-
and postmenopausal women. This suggests that fat mass is related
to bone metabolism, whereas lean mass is not. Thus, the two soft
tissue compartments could interact with the skeleton through
quite different mechanisms. The common origins of osteoblasts,
myocytes, and other connective tissue cells, together with their re-
sponse to similar growth regulatory signals and to loading, proba-
bly underlie the bone-lean correlation, which is strongest in
children and young adults. However, fat tissue regulates bone
turnover in both premenopausal and postmenopausal life, so its
influence on bone mass is likely to increase over time, particularly
in the absence of other major players such as estrogen. This would
account for the frequent observation that fat mass is a more signif-
icant correlate of bone density later in life, particularly in women.
Bone-active hormones influenced by feeding
The advent of sensitive markers of bone resorption has made
apparent that osteoclast activity is acutely responsive to food
ingestion, such that these assessments are always made in the fast-
ing state to eliminate problems caused by eating. It is now also rec-
ognized that osteoblast activity is also influenced by short-term
changes in nutrition. The study of Ihle and Loucks [75] has shown
that a 30% energy restriction over a period of five days will reduce
markers of osteoblast activity by 10%, and a 70% energy restriction
over this period reduces osteoblast markers by up to 30%, with
bone resorption increasing by about the same amount. These
changes in bone turnover are accompanied by reductions in estra-
diol, insulin, IGF1 and thyroid hormones. Other hormonal interme-
diaries are likely to be involved in signaling eating activity to bone.
Glucose ingestion increases calcitonin secretion [76] and decreases
parathyroid hormone [77,78]. Amylin is co-secreted with insulin,
and potently inhibits bone resorption [79], so might contribute
to these effects. Fat or protein ingestion also reduce bone resorp-
tion in humans [80–82]. This could be mediated by changes in
parathyroid hormone, amylin and calcitonin, but there are other
potential players since these nutrients stimulate secretion of the
incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-
dependent insulinotropic polypeptide (GIP), which act to enhance
postprandial insulin secretion. GLP-1 and GIP do not acutely influ-
ence bone resorption [81] but GIP stimulates osteoblast prolifera-
tion, can attenuate post-ovarectomy bone loss [83,84], and the
GIP-receptor knockout mouse shows decreased bone size, mass,
and formation rate [85]. Parenteral administration of the related
peptide, GLP-2, produces a dose-dependent reduction in serum
C-terminal telopeptide of type I collagen [81], and GLP-2 adminis-
tration over a 4-month period decreased bone resorption and in-
creased bone density in postmenopausal women [86]. Consistent
with these findings, deletion of GLP-2 receptor leads to marked
skeletal deficits in growing mice [87]. Ghrelin is a further candidate
hormone that might mediate feeding effects on bone.
Other mechanistic possibilities
Recently, the fat–bone connection has assumed a new complex-
ity with the suggestion that bone might regulate intermediary
metabolism. Thus, Ferron et al. [88] have shown that the adminis-
tration of uncarboxylated osteocalcin to mice for 28 days increases
their insulin sensitivity and decreases their fat mass. The signifi-
cance of this to normal human physiology and disease states re-
mains to be established.
It has also been suggested that marrow adipocytes might di-
rectly impact on bone cell function [89]. Adipocytes and
osteoblasts are derived from the same pool of pluripotent mesen-
chymal stem cells, the fate of which is determined by local and sys-
temic influences. There is a growing body of evidence for a
reciprocal relationship between marrow adiposity and bone for-
mation, and PPARc agonists, such as rosiglitazone, drive this bal-
ance in the direction of the adipocyte, resulting in bone loss [90].
Some fatty acids can have a similar effect in vitro [91]. Also, inflam-
matory cytokines (TNFa_and IL-6) from marrow adipocytes could
directly promote bone resorption [92]. At present, it remains
uncertain whether an increase in marrow fat alters bone metabo-
lism or simply occurs as an epiphenomenon in response to a de-
cline in bone formation.
Conclusions
Fat and bone are linked by a multitude of pathways, which ulti-
mately serve the function of providing a skeleton appropriate to
the mass of adipose tissue it is carrying. Adiponectin, insulin/amy-
lin/preptin, leptin and adipocytic estrogens are all likely to be in-
volved in this connection. In the clinic, the key issues are that
obesity is protective against osteoporosis, but underweight is a
major preventable risk factor for fractures.
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