Obesity and Osteoporotic Fractures: Solving the Paradox

Obesity is a global health issue linked to conditions like metabolic syndrome and heart disease, but its relationship with fracture risk is complex. While higher body mass index (BMI) is associated with increased bone mineral density (BMD) due to mechanical loading, it does not uniformly protect against fractures. Obese individuals face higher risks of proximal humerus and ankle fractures, along with propensity for increased falls and sarcopenic obesity. Higher fat mass, particularly visceral adiposity, correlates with lower bone quality and increased fracture risk, independent of BMD. Obesity triggers inflammatory pathways (e.g., TNF-α, Monocyte Chemotactic Protein-1 [MCP-1]) and adipokine imbalances (e.g., adiponectin, leptin), impairing bone formation and resorption. Vitamin D deficiency and secondary hyperparathyroidism further exacerbate cortical bone loss. Diagnostic challenges arise as dual-energy X-ray absorptiometry and FRAX tools may underestimate fracture risk in obesity. Preventive strategies emphasize lifestyle interventions, including moderate weight loss targeting subcutaneous fat, resistance training, and optimal dairy intake to enhance BMD.