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"Menopause and Obesity Is Not a Good Match for Bone Health"

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Menopause and Obesity Is Not a Good Match for Bone Health

Once Obesity was Believed to be Protective Against Osteoporosis. The new scientific findings reveal the harsh truth about the correlations between menopause and obesity that affects bone health.


Did you know there was a time when carrying extra weight was thought to shield you from osteoporosis, especially during the menopause years? It seems a bit counterintuitive now, doesn't it? Well, let's dive into why the tide of opinion has changed and why we need to pay attention to obesity and bone health together.


Back in the day, the extra cushioning from body fat was believed to protect bones and even prevent fractures if someone took a tumble. However, as research has evolved, so has our understanding of how obesity actually interacts with our bone health. According to a 2020 article in the Journal of Musculoskeletal and Neuronal Interactions, the scales have tipped the other way. The article points out that obesity, particularly at the menopausal stage, isn't the bone-protecting friend we thought it was. Instead, it brings challenges like reduced skeletal strength, systemic inflammation, increased bone marrow fat, and even the way belly fat impacts our bones.


Globally, osteoporosis affects a staggering number of over 200 million people, leading to millions of fractures annually in the U.S. alone. And yes, this includes folks across the board – not just those with a BMI under 30. Studies even link abdominal fat with bone density issues like osteoporosis and osteopenia.


Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. BMI is imperfect, but a widely used measure of obesity as it provides a crude measure. The WHO defines obesity as a BMI of 30kg/m2 or higher, while a person with a BMi of 25-30kg/m2 is considered as overweight.  
Osteoporosis is defined as the T-score of the bone mineral density (BMD) of 2.5 SD or more below the mean adult value. Osteopenia is measured using BMD with a T-score between 1.0-2.5.


So, what's the deal with menopause and obesity impacting to our bones? It turns out, our adipose tissue (a fancy term for body fat) is much more than an energy storage space. It acts like an endocrine organ, chatting with our bones through hormones and enzymes like leptin, adiponectin, and those pesky pro-cytokines. This communication can affect everything from bone formation to how we metabolize vitamin D – crucial for bone health but often found in lower levels in those with higher body fat.


person falling picture

Skeletal architect


And here's a fun (or not so fun) fact: The way we fall changes with our body weight. Those extra pounds can make us more likely to fall backward or sideways, leading to different types of fractures than those who are leaner might experience. Obese women experience more fractures in the ankle, leg, humerus, and vertebral column and fewer in the wrist, hip, and pelvis.


Nerdy Info:
1.       Obesity can cause or exacerbate chronic health problems, such as diabetes, cardiovascular disease, arthritis, hypoventilation syndrome, sleep apnea and hypertension. These conditions are strongly associated with peripheral neuropathy, autonomic dysfunction with orthostatic hypotension and instability as well as general weakness.
2.       Excessive body weight is linked with reduced ability in performing daily tasks, such as walking unaided or climbing upstairs, which again increases the risks of falls.
3.       Increasing body weight adds pressure on the heels, which compromises postural stability and balance ability.
4.       The central adiposity in older women, measured by the waist-to-hip ratio, plays a major in independent role as a fall-related indicator.


Let's not forget about dynapenic and sarcopenic obesity – conditions where obesity is paired with loss of muscle strength or mass, raising the risk of falls, reduced bone density, and yep, more fractures.


Estrogens and Leptin

And estrogen? It plays a key role in bone health, with obese post-menopausal women showing higher levels, which could impact bone protection. Leptin, a hormone from fat cells, also enters this complex dance, influencing everything from appetite to bone mass. But, as with everything, balance is key. Too much leptin can lead to resistance, tipping the scales towards bone health issues.



As we age, estrogen levels lower, which is not a great environment for bone health. Leptin levels increase as we gain body fat. The more we accumulate adipose tissues, the more leptin we obtain. Thus, it is harder to reach satiety when we eat because hangry leptin demands more. Adiponectin is the one that controls the body fat formation and utilization. Unfortunately, the adiponectin concentrations are affected by the ratio of amount of adipose tissue. So, obese individuals have lower adiponectin concentrations, that sounds good, but the truth is hidden behind the other roles of adiponectin.

Adiponectin's relationship with bone health is a fascinating area of research that highlights the intricate connections between metabolism and the skeletal system. The impact of adiponectin on bone health is complex and appears to involve multiple pathways, reflecting both positive and negative effects on bone structure and strength.


On one hand, adiponectin is known to play a role in regulating bone metabolism through its effects on bone cells. It influences the function of osteoblasts (cells responsible for bone formation) and osteoclasts (cells responsible for bone resorption), which are crucial for maintaining bone health and remodeling. Adiponectin can promote osteoblastogenesis (the formation of osteoblasts) and suppress osteoclast differentiation, suggesting a potential protective role in bone density and strength.


However, studies have shown mixed results, with some research suggesting that high levels of adiponectin might be associated with lower bone mineral density (BMD) in certain populations, potentially due to its role in energy metabolism and insulin sensitivity. This paradoxical effect suggests that the relationship between adiponectin and bone health may be influenced by various factors, including age, sex, body composition, and hormonal status.


Nerdy Info:
Adiponectin is a protein hormone that plays an essential role in regulating glucose levels and fatty acid breakdown in the body. Produced by adipose (fat) tissue, it's unique because, unlike other hormones secreted by adipose tissue which typically increase with fat mass, adiponectin levels tend to decrease when fat mass increases. This characteristic is particularly interesting because it suggests a protective role of adiponectin against obesity-related conditions such as type 2 diabetes, cardiovascular disease, and insulin resistance.
  Adiponectin enhances the body's sensitivity to insulin, making it crucial for maintaining glucose homeostasis. It also has anti-inflammatory properties, contributing to its protective effects against atherosclerosis (the buildup of fats, cholesterol, and other substances in and on your artery walls) and other inflammation-related diseases.


Low-grade Inflammation


Speaking of low-grade inflammation, higher levels of adiponectin concentrations decrease inflammatory cytokines. However, once gained body fat, adiponectin levels go down and increases malicious cytokine (TNF-alpha, IL-6) levels up. As it is renowned for bad environment for bone health, inflammation can inhibit strong bone formation.  


Low-grade inflammation is indeed a significant factor that can negatively affect bone health, with key inflammatory markers such as Tumor Necrosis Factor-alpha (TNF-α) and Interleukin-6 (IL-6) playing pivotal roles. These cytokines are not only central to the body's inflammatory response but also directly influence bone metabolism, affecting both bone formation and resorption processes.


Nerdy Info:
TNF-α is a pro-inflammatory cytokine involved in systemic inflammation. It has been shown to stimulate bone resorption by increasing the formation and activity of osteoclasts, the cells responsible for breaking down bone tissue. This can lead to decreased bone density and an increased risk of osteoporosis, particularly in chronic inflammatory conditions such as rheumatoid arthritis, where TNF-α levels are elevated.
IL-6 is another cytokine with a dual role in immunity and inflammation. Similar to TNF-α, IL-6 can promote osteoclastogenesis, leading to increased bone resorption. High levels of IL-6 have been associated with bone loss and increased risk of osteoporosis. Moreover, IL-6 can influence the differentiation of osteoblasts, the cells responsible for bone formation, although its effects on bone formation are more complex and can depend on the context and the presence of other factors.

The interplay between TNF-α, IL-6, and bone health underscores the importance of managing low-grade inflammation to protect against bone-related diseases. Chronic low-grade inflammation can be a silent threat, often going unnoticed while it undermines bone integrity over time.


High Fat Diet and Bone Microenvironment

Obesity induced by high fat diet (HFD) is associated with increased bone quantity (larger bone size and mineral content) but decreased bone quality (lower side-independent mechanical properties). Another study showed that the deterioration in trabecular bone micro-architecture in mice. Obesity induced by HFD causes increased bone resorption but increased bone marrow adiposity as well which led to bone resorption.


Fat Bone Marrow and Osteoporosis

The relationship between fat in the bone marrow and osteoporosis is an area of growing interest in medical research, highlighting the complex interplay between bone health and body composition. Bone marrow adiposity (BMA), or the presence of fat cells within the bone marrow, is a phenomenon that increases with age and has been associated with bone metabolic diseases, including osteoporosis.

The role of bone marrow fat has emerged as another significant factor in understanding the pathophysiology of this condition. A few key points highlight the connection between bone marrow fat and osteoporosis:


1.       Negative correlation with bone density: Higher levels of marrow adiposity have been found to correlate negatively with bone mineral density (BMD). This relationship suggests that as bone marrow fat increases, bone density tends to decrease, which can contribute to the development of osteoporosis.


2.       Regulatory role in bone metabolism: Bone marrow adipocytes (fat cells) are not merely passive storage cells; they actively secrete factors that can influence the function of osteoblasts and osteoclasts. Some of these adipocyte-derived factors, including fatty acids and adipokines, can inhibit bone formation and promote bone resorption, further contributing to bone loss.


3.       Indicator of bone quality: Beyond affecting bone density, increased bone marrow adiposity is also associated with changes in bone quality, such as alterations in bone microarchitecture. These changes can further compromise bone strength and increase the risk of fractures.


The new findings sound scary because it can lower the BMD, accelerates bone loss, and lowers the bone quality.

Vitamin D


Last but not least, vitamin D – our sunshine vitamin. It's harder for our bodies to use when we're carrying extra weight, thanks to its fat-soluble nature and our reduced sun exposure. It is true that vitamin D deficiency among obese individuals is a well-documented phenomenon, presenting a paradoxical situation where the body's fat tissues, which can store vitamin D, contribute to its decreased bioavailability. The relationship between obesity and vitamin D deficiency involves several key aspects:

1.       Fat Solubility of Vitamin D: Vitamin D is a fat-soluble vitamin, meaning it can be stored in fat tissues. In obese individuals, higher amounts of body fat can sequester more vitamin D, making it less available for use by the body. This sequestration reduces the circulating levels of vitamin D, potentially leading to deficiency despite adequate intake or production.


2.       Reduced Sun Exposure: Vitamin D is unique among vitamins because the body can synthesize it through skin exposure to sunlight. However, obese individuals may have reduced outdoor physical activity, leading to less sun exposure and, consequently, decreased vitamin D synthesis.


3.       Impaired Metabolism: Obesity can alter vitamin D metabolism. The conversion of vitamin D to its active form involves the liver and kidneys, and obesity-related conditions such as fatty liver disease can impair these organs' function, affecting vitamin D activation.


4.       Inflammatory Factors: Obesity is often associated with low-grade inflammation, which can also impact vitamin D status. Inflammatory cytokines might interfere with vitamin D metabolism and signaling.



Summary: Menopause, Obesity, and Bone Health: A Complex Triad


Menopause brings about a whirlwind of changes in a woman's body, driven by shifts in hormone levels, particularly a decrease in estrogen. This hormonal adjustment can lead to increased bone loss, making postmenopausal women more susceptible to osteoporosis.


But here's where the plot thickens: While menopause is an unavoidable milestone, obesity—a condition often linked to an increased risk of various health issues, including heart disease and diabetes—is a controllable factor. Contrary to the outdated belief, current research indicates that obesity does not spare women from the risks of bone loss. In fact, the excess weight can exacerbate the situation.


The Science Behind the Scenes


The relationship between obesity, menopause, and bone health is intricate. Adipose tissue, or body fat, isn't just a passive energy reserve; it actively secretes hormones and substances like leptin and adiponectin, which play roles in energy metabolism and inflammation. These substances have been found to interact with bone health in complex ways, influencing both bone formation and resorption. Moreover, obesity can lead to a state of chronic low-grade inflammation, further complicating the body's ability to maintain healthy bones.


Additionally, vitamin D—a crucial component for bone health—is often found in lower levels in individuals with higher body fat percentages. This deficiency can undermine the body's ability to absorb calcium, further jeopardizing bone strength.


While we can't dodge menopause, we can certainly take proactive steps to manage our weight and mitigate its impact on our bones. Embracing a healthy lifestyle, including a balanced diet rich in nutrients essential for bone health and engaging in regular weight-bearing exercises, can be powerful tools in our arsenal against bone loss.

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Gkastaris K, Goulis DG, Potoupnis M, Anastasilakis AD, Kapetanos G. Obesity, osteoporosis and bone metabolism. J Musculoskelet Neuronal Interact. 2020 Sep 1;20(3):372-381. PMID: 32877973; PMCID: PMC7493444.

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