# Adolescent Body Mass Index, Weight Trajectories to Adulthood, and Osteoporosis Risk

## TL;DR

Higher BMI in adolescence is linked to lower osteoporosis risk in adulthood, with underweight individuals facing the highest risk.

## Contribution

This study identifies a strong inverse relationship between adolescent BMI and osteoporosis risk, adjusted for BMI changes into adulthood.

## Key findings

- Underweight adolescents who remained underweight had the highest osteoporosis risk in adulthood.
- Obesity in adolescence was associated with reduced osteoporosis risk in women but not in men.
- Weight gain from underweight in adolescence was linked to lower osteoporosis risk.

## Abstract

This cohort study evaluates the association between adolescent body mass index (BMI) and osteoporosis risk, while accounting for BMI change during early adulthood.

What is the association between adolescent body mass index (BMI) and osteoporosis risk while accounting for BMI change during early adulthood?

This cohort study of 1.1 million Israeli adolescents found a direct inverse association between adolescent BMI for osteoporosis incidence, which persisted in various models adjusted for sociodemographic confounders and preexisting illnesses. The highest risk was observed in those remaining underweight from adolescence to adulthood, while weight gain from underweight was associated with reduced risk.

These findings suggest that BMI at a young age and its trajectory to adulthood are associated with risk for osteoporosis in adult life.

There are limited data regarding adolescent weight among healthy individuals and their trajectory through early adulthood with respect to bone health.

To assess the association between adolescent body mass index (BMI) and osteoporosis risk while accounting for BMI change during early adulthood.

A retrospective population-based cohort study from 1967 to 2019. Participants were Israeli-born adolescents aged 16 to 19 years who were evaluated for military service. Data were analyzed from January 2023 to March 2025.

Weight and height were measured to calculate BMI at adolescence, and additional sociodemographic and medical data were collected. Health status at baseline and incident cancer and diabetes throughout adulthood were strictly controlled.

Osteoporosis diagnosis until 2022, recorded in the osteoporosis registry of Maccabi Healthcare Services (the second-largest Israeli health care system). Cox proportional hazard models were applied. Adult BMI measurement was available for 74% of the study population and was used to assess the association between adolescence-to-adulthood weight trajectory and incident osteoporosis.

In this cohort study of 1 083 491 adolescents, 21 497 (4.58%) women and 6929 (1.13%) men were enrolled in the osteoporosis registry during a cumulative follow-up of 19 400 208 person-years (mean [SD] age at follow-up, 23.7 [8.5] years). There was a consistent inverse association between adolescent BMI and osteoporosis risk in adulthood. The crude incidence rate of osteoporosis decreased from 330.2 per 100 000 person-years among those with extreme underweight (<3rd percentile) to 78.9 among those with obesity (≥95th percentile). Adjusted hazard ratios for osteoporosis ranged from 1.88 (95% CI, 1.74–2.04) to 0.83 (95% CI, 0.77–0.89) in women and from 1.82 (95% CI, 1.64–2.01) to 1.04 (95% CI, 0.93–1.16) in men, using normal BMI as the reference. A sex-specific difference in osteoporosis risk was notable, with obesity not showing a protective association in men compared with women. The findings were robust across multiple models and sample restrictions, and the highest risk was observed in individuals who remained underweight from adolescence into adulthood.

In this cohort study, BMI at a young age and its trajectory to adulthood were significantly associated with risk for osteoporosis in adult life.