The contested association between MASLD and osteoporosis: a narrative review of heterogeneous evidence and modifying...

Metabolic dysfunction-associated steatotic liver disease (MASLD) and osteoporosis are prevalent chronic metabolic disorders. Although a pathophysiological plausibility for their association exists, clinical evidence demonstrates substantial controversy and heterogeneity.

First, review and critically evaluate the controversial evidence regarding their association; second, analyze the sources of research heterogeneity, elucidate the regulatory roles of key effect modifiers; and third, integrate shared pathophysiological mechanisms to provide insights for future research and clinical practice.

We conducted a literature search in PubMed, Embase, Cochrane Library, Scopus, and Web of Science up to September 16, 2025, using relevant keywords and terms.

Current studies have reported varying associations between MASLD and bone mineral density, ranging from negative to null to positive. The relationship between MASLD and bone metabolism exhibits highly complex, conditional, and context-dependent characteristics. The strength and direction of this association may be significantly influenced by a range of effect modifiers, including gender, age, ethnicity, visceral fat distribution, the severity of MASLD, and the sites of skeletal measurement. Factors such as chronic inflammatory responses, insulin resistance, and adipokine dysregulation may be involved in modulating this association.

The association between MASLD and osteoporosis is highly complex, conditional, and context-dependent, as its direction and magnitude are significantly modulated by multiple effect modifiers. Future research requires large-scale, long-term, multicenter prospective cohort studies to thoroughly investigate their causal relationship and underlying mechanisms.