# Metabolic dysfunction-associated steatotic liver disease and bone mineral density in type 2 diabetes mellitus: insights from a single-center cross-sectional study in North India

## TL;DR

This study finds that liver disease linked to type 2 diabetes is associated with lower bone density in specific areas of the skeleton, especially in older men.

## Contribution

The study reveals site-specific bone mineral density reductions in type 2 diabetes patients with liver disease in a North Indian population.

## Key findings

- MASLD was associated with significantly lower lumbar spine BMD in type 2 diabetes patients.
- Hip BMD was positively linked to hepatic steatosis in T2DM patients.
- Forearm and proximal femur BMD showed no significant differences between groups.

## Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD), recently redefined from non-alcoholic fatty liver disease, commonly coexists with type 2 diabetes mellitus and may adversely affect skeletal health through inflammation and insulin resistance. However, research on site-specific bone mineral density (BMD) effects in South Asian populations, particularly Indians, remains limited. This study aimed to evaluate the association between MASLD and BMD at different skeletal sites among adults with type 2 diabetes mellitus in North India.

This cross-sectional study included 100 adults (50 with T2DM and 50 controls) at a tertiary care center in Jaipur, India. MASLD was evaluated using the fibrosis-4 (FIB-4) index, hepato-renal index, and two-dimensional shear wave elastography. BMD at lumbar spine (L1-L4), left total hip (proximal femur), and left forearm was assessed by dual-energy X-ray absorptiometry. Associations between MASLD parameters and BMD were analyzed using multivariable linear regression, adjusting for age, sex, and smoking status.

T2DM patients showed significantly lower lumbar spine (L1-L4) BMD (0.93 vs. 0.98 g/cm2; P = 0.026) and T-scores (-1.33 vs. -0.72; P = 0.004), especially in males ≥50 years. No statistically significant differences were observed in proximal femur and forearm BMD between groups. FIB-4 scores were higher (P = 0.004), with 60% at intermediate-to-high fibrosis risk versus 28% of controls; advanced fibrosis occurred in 10% vs. 2%. Hepatic steatosis positively associated with hip BMD (β=0.738; P = 0.022).

This study establishes significant, site-specific associations between MASLD and reduced bone mineral density in type 2 diabetes mellitus patients, particularly affecting trabecular-rich skeletal sites. The complex relationship between hepatic steatosis and skeletal health highlights the multisystemic nature of metabolic dysfunction. These findings support integrating bone health assessments and non-invasive hepatic fibrosis screening into routine diabetes care to improve early risk stratification.