{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T21:35:17Z","timestamp":1790631317372,"version":"4.1.0"},"reference-count":43,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T00:00:00Z","timestamp":1786579200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"University of Oradea, Romania"},{"id":[{"id":"https:\/\/ror.org\/00wzhv093","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Body mass index (BMI) has a complex relationship with skeletal health. Higher BMI is often associated with higher bone mineral density (BMD), but this apparent densitometric advantage may not fully reflect bone microarchitecture. Trabecular bone score (TBS) may provide complementary information in overweight and obese postmenopausal women. This study evaluated the associations between BMI, BMD, and TBS in postmenopausal women and assessed whether increased BMI is associated with discordant skeletal phenotypes characterized by non-osteoporotic densitometric status but impaired trabecular microarchitecture. Materials and Methods: This retrospective observational study screened 110 DXA\/TBS reports from patients evaluated in a tertiary DXA center. Inclusion criteria were female sex, postmenopausal status, available BMI or sufficient anthropometric data for BMI calculation, valid lumbar spine DXA, at least one valid hip DXA assessment, and valid lumbar TBS assessment. Four cases were excluded: two male patients and two non-menopausal female patients. The final analytical cohort included 106 postmenopausal women. Lumbar spine and hip BMD, T-scores, TBS, Bone Resilience Index, anthropometric variables, and menopausal variables were extracted from DXA\/TBS reports. BMI was analyzed both continuously and by category: under\/normal-weight, overweight, and obesity. Correlation analyses, group comparisons, and linear regression models were used to evaluate the relationship between BMI and skeletal parameters. Discordant skeletal phenotypes were defined descriptively as non-osteoporotic DXA findings combined with degraded TBS. Results: The final cohort had a mean age of 65.2 \u00b1 7.6 years and a mean BMI of 27.3 \u00b1 4.5 kg\/m2. BMI was positively associated with lumbar spine BMD (r = 0.392, p &lt; 0.001), minimum femoral neck BMD (r = 0.382, p &lt; 0.001), and minimum total hip BMD (r = 0.508, p &lt; 0.001), but negatively associated with TBS (r = \u22120.307, p = 0.001). Mean TBS decreased across BMI categories, from 1.283 \u00b1 0.084 in the under\/normal-weight group to 1.255 \u00b1 0.088 in the overweight group and 1.199 \u00b1 0.109 in the obesity group. In the fully adjusted regression model including BMI, age, years since menopause, lumbar spine BMD, and lowest hip T-score, BMI remained an independent negative predictor of TBS (\u03b2 = \u22120.0126, p &lt; 0.001). Discordant skeletal phenotypes combining non-osteoporotic DXA status with degraded TBS were more frequent in patients with obesity. Conclusions: In postmenopausal women, higher BMI was associated with higher BMD but lower TBS, supporting a divergent relationship between densitometric findings and DXA-derived trabecular texture parameters. These findings suggest that TBS may complement BMD in describing skeletal imaging status in overweight and obese women. Because fracture outcomes and complete clinical risk data were not available, the present results should be interpreted as evidence of imaging discordance rather than direct evidence of clinical underdiagnosis or misclassification.<\/jats:p>","DOI":"10.3390\/medicina62081555","type":"journal-article","created":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T12:47:11Z","timestamp":1786625231000},"page":"1555","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["The Obesity\u2013Bone Paradox in Postmenopausal Women: Divergent Associations of BMI with Bone Mineral Density and Trabecular Bone Score in a Real-World DXA Cohort"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4107-7066","authenticated-orcid":false,"given":"Robert","family":"Bot","sequence":"first","affiliation":[{"name":"Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410073 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7810-8925","authenticated-orcid":false,"given":"Simona Daniela","family":"Cavalu","sequence":"additional","affiliation":[{"name":"Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410073 Oradea, Romania"},{"name":"Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410073 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"650","DOI":"10.1111\/joim.12369","article-title":"Osteoporosis: The evolution of a diagnosis","volume":"277","author":"Lorentzon","year":"2015","journal-title":"J. Intern. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"518","DOI":"10.1002\/jbmr.2176","article-title":"Trabecular Bone Score: A Noninvasive Analytical Method Based Upon the DXA Image","volume":"29","author":"Silva","year":"2014","journal-title":"J. Bone Miner. Res."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1501","DOI":"10.1007\/s00198-023-06817-4","article-title":"Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: Results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging","volume":"34","author":"Shevroja","year":"2023","journal-title":"Osteoporos. Int."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"101452","DOI":"10.1016\/j.jocd.2023.101452","article-title":"Clinical Use of Trabecular Bone Score: The 2023 ISCD Official Positions","volume":"27","author":"Goel","year":"2024","journal-title":"J. Clin. Densitom."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1007\/s00223-015-9980-x","article-title":"Adjusting Fracture Probability by Trabecular Bone Score","volume":"96","author":"McCloskey","year":"2015","journal-title":"Calcif. Tissue Int."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"940","DOI":"10.1002\/jbmr.2734","article-title":"A Meta-Analysis of Trabecular Bone Score in Fracture Risk Prediction and Its Relationship to FRAX","volume":"31","author":"McCloskey","year":"2016","journal-title":"J. Bone Miner. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1016\/j.ecl.2024.07.001","article-title":"Utility of Trabecular Bone Score in the Management of Patients with Osteoporosis","volume":"53","author":"Lewiecki","year":"2024","journal-title":"Endocrinol. Metab. Clin. N. Am."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"694","DOI":"10.20945\/2359-3997000000559","article-title":"Update on trabecular bone score","volume":"66","author":"Palomo","year":"2022","journal-title":"Arch. Endocrinol. Metab."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"145","DOI":"10.12659\/MSM.895512","article-title":"Body Mass Index May Positively Correlate with Bone Mineral Density of Lumbar Vertebra and Femoral Neck in Postmenopausal Females","volume":"22","author":"Wu","year":"2016","journal-title":"Med. Sci. Monit."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2561227","DOI":"10.1080\/07853890.2025.2561227","article-title":"Association of body mass index and bone mineral density in postmenopausal women: A systematic review and meta-analysis","volume":"57","author":"Cai","year":"2025","journal-title":"Ann. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1330","DOI":"10.1007\/s00198-004-1640-3","article-title":"Body mass index as a predictor of fracture risk: A meta-analysis","volume":"16","author":"Kanis","year":"2005","journal-title":"Osteoporos. Int."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1002\/jbmr.2017","article-title":"A Meta-Analysis of the Association of Fracture Risk and Body Mass Index in Women","volume":"29","author":"Johansson","year":"2014","journal-title":"J. Bone Miner. Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1359\/jbmr.091004","article-title":"Obesity and fractures in postmenopausal women","volume":"25","author":"Premaor","year":"2010","journal-title":"J. Bone Miner. Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1043","DOI":"10.1016\/j.amjmed.2011.06.013","article-title":"Obesity Is Not Protective against Fracture in Postmenopausal Women: GLOW","volume":"124","author":"Compston","year":"2011","journal-title":"Am. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"414","DOI":"10.1097\/BOR.0000000000000182","article-title":"Obesity and fractures in postmenopausal women","volume":"27","author":"Compston","year":"2015","journal-title":"Curr. Opin. Rheumatol."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Turcotte, A.-F., O\u2019connor, S., Morin, S.N., Gibbs, J.C., Willie, B.M., Jean, S., and Gagnon, C. (2021). Association between obesity and risk of fracture, bone mineral density and bone quality in adults: A systematic review and meta-analysis. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0252487"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2203515","DOI":"10.1080\/07853890.2023.2203515","article-title":"Obesity and risk of fracture in postmenopausal women: A meta-analysis of cohort studies","volume":"55","author":"Liu","year":"2023","journal-title":"Ann. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e466","DOI":"10.1210\/clinem\/dgad415","article-title":"Obesity and Skeletal Fragility","volume":"109","author":"Chen","year":"2024","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Pi\u00f1ar-Gutierrez, A., Garc\u00eda-Fontana, C., Garc\u00eda-Fontana, B., and Mu\u00f1oz-Torres, M. (2022). Obesity and Bone Health: A Complex Relationship. Int. J. Mol. Sci., 23.","DOI":"10.3390\/ijms23158303"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Rinonapoli, G., Pace, V., Ruggiero, C., Ceccarini, P., Bisaccia, M., Meccariello, L., and Caraffa, A. (2021). Obesity and Bone: A Complex Relationship. Int. J. Mol. Sci., 22.","DOI":"10.3390\/ijms222413662"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Palermo, A., Tuccinardi, D., Defeudis, G., Watanabe, M., D\u2019onofrio, L., Pantano, A.L., Napoli, N., Pozzilli, P., and Manfrini, S. (2016). BMI and BMD: The Potential Interplay between Obesity and Bone Fragility. Int. J. Environ. Res. Public Health, 13.","DOI":"10.3390\/ijerph13060544"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1166","DOI":"10.1097\/GME.0000000000001375","article-title":"Trabecular bone score of postmenopausal women is positively correlated with bone mineral density and negatively correlated with age and body mass index","volume":"26","author":"Torgutalp","year":"2019","journal-title":"Menopause"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1016\/j.afos.2017.02.001","article-title":"The correlation between bone mineral density\/trabecular bone score and body mass index, height, and weight","volume":"3","author":"Kim","year":"2017","journal-title":"Osteoporos. Sarcopenia"},{"key":"ref_24","first-page":"374","article-title":"The Correlation between Trabecular Bone Score and Lumbar Spine Bone Mineral Density in Patients with Normal and High Body Mass Index","volume":"44","author":"Rajaei","year":"2019","journal-title":"Iran. J. Med. Sci."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/j.afos.2020.08.002","article-title":"Associations between bone mineral density, trabecular bone score, and body mass index in postmenopausal females","volume":"6","author":"Shayganfar","year":"2020","journal-title":"Osteoporos. Sarcopenia"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Jose, A., Cherian, K.E., Nandyal, M.B., Jiwanmall, S.A., Kattula, D., Paul, T.V., and Kapoor, N. (2021). Trabecular Bone Score and Bone Mineral Density in Postmenopausal Women with Morbid Obesity\u2014A Clinical Paradox. Med. Sci., 9.","DOI":"10.3390\/medsci9040069"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"529","DOI":"10.36740\/WLek202003124","article-title":"Bone mineral density and trabecular bone score in postmenopausal women with knee osteoarthritis and obesity","volume":"73","author":"Povoroznyuk","year":"2020","journal-title":"Wiad. Lek."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1016\/j.jocd.2016.11.003","article-title":"Densitometer-Specific Differences in the Correlation Between Body Mass Index and Lumbar Spine Trabecular Bone Score","volume":"20","author":"Mazzetti","year":"2017","journal-title":"J. Clin. Densitom."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1137","DOI":"10.1002\/jbmr.5650090802","article-title":"The diagnosis of osteoporosis","volume":"9","author":"Kanis","year":"1994","journal-title":"J. Bone Miner. Res."},{"key":"ref_30","unstructured":"International Society for Clinical Densitometry (2023). 2023 ISCD Official Positions Adult [Internet]. ISCD, International Society for Clinical Densitometry. Available online: https:\/\/iscd.org\/official-positions."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"101437","DOI":"10.1016\/j.jocd.2023.101437","article-title":"DXA Reporting Updates: 2023 Official Positions of the International Society for Clinical Densitometry","volume":"27","author":"Krueger","year":"2024","journal-title":"J. Clin. Densitom."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"101435","DOI":"10.1016\/j.jocd.2023.101435","article-title":"Executive Summary of the 2023 Adult Position Development Conference of the International Society for Clinical Densitometry: DXA Reporting, Follow-up BMD Testing and Trabecular Bone Score Application and Reporting","volume":"27","author":"Shuhart","year":"2024","journal-title":"J. Clin. Densitom."},{"key":"ref_33","unstructured":"WHO Consultation (2000). Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ. Tech. Rep. Ser., 894, 1\u2013253."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1210\/jc.2012-3118","article-title":"For the Manitoba Bone Density Program. TBS (Trabecular Bone Score) and Diabetes-Related Fracture Risk","volume":"98","author":"Leslie","year":"2013","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"5045","DOI":"10.1210\/jc.2010-0226","article-title":"High-Resolution Peripheral Quantitative Computed Tomographic Imaging of Cortical and Trabecular Bone Microarchitecture in Patients with Type 2 Diabetes Mellitus","volume":"95","author":"Burghardt","year":"2010","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"553","DOI":"10.4239\/wjd.v13.i7.553","article-title":"Factors associated with trabecular bone score in postmenopausal women with type 2 diabetes and normal bone mineral density","volume":"13","author":"Fazullina","year":"2022","journal-title":"World J. Diabetes"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Trandafir, A.-I., Sima, O.-C., Gheorghe, A.-M., Ciuche, A., Cucu, A.-P., Nistor, C., and Carsote, M. (2023). Trabecular Bone Score (TBS) in Individuals with Type 2 Diabetes Mellitus: An Updated Review. J. Clin. Med., 12.","DOI":"10.3390\/jcm12237399"},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Sulis, S., Falbov\u00e1, D., Be\u0148u\u0161, R., \u0160v\u00e1bov\u00e1, P., Hoz\u00e1kov\u00e1, A., and Vorobe\u013eov\u00e1, L. (2024). Sex and Obesity-Specific Associations of Ultrasound-Assessed Radial Velocity of Sound with Body Composition. Appl. Sci., 14.","DOI":"10.3390\/app14167319"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1080\/03014460.2022.2105398","article-title":"Contribution of Environmental Factors and Female Reproductive History to Hypertension and Obesity Incidence in Later Life","volume":"49","year":"2022","journal-title":"Ann. Hum. Biol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1","DOI":"10.4158\/GL-2020-0524SUPPL","article-title":"American Association of Clinical Endocrinologists\/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis\u20142020 Update","volume":"26","author":"Camacho","year":"2020","journal-title":"Endocr. Pract."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1595","DOI":"10.1210\/jc.2019-00221","article-title":"Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline","volume":"104","author":"Eastell","year":"2019","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"2517","DOI":"10.1007\/s00198-022-06549-x","article-title":"Updated trabecular bone score accounting for the soft tissue thickness (TBSTT) demonstrated significantly improved bone microstructure with denosumab in the FREEDOM TBS post hoc analysis","volume":"33","author":"Hans","year":"2022","journal-title":"Osteoporos. Int."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1007\/s00198-025-07421-4","article-title":"Advancing trabecular bone score (TBS): Clinical performance of TBS version 4.0 with direct correction for soft tissue thickness\u2014The osteolaus study","volume":"36","author":"Gatineau","year":"2025","journal-title":"Osteoporos. Int."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/8\/1555\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T13:06:20Z","timestamp":1786626380000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/8\/1555"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,13]]},"references-count":43,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["medicina62081555"],"URL":"https:\/\/doi.org\/10.3390\/medicina62081555","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,13]]}}}