Hidden Skeletal Consequences of Adolescent Obesity

New research reveals long-term bone health implications

Research presented at ENDO 2025 suggests that adolescents with both obesity and type 2 diabetes could be at a higher risk for fractures and osteoporosis later in life. Lead researcher Fida Bacha, MD, discusses her group’s findings as well as the impact of insulin resistance and hyperglycemia on bone development in this population.

In new research presented in July at ENDO 2025 in San Francisco, Calif., lead researcher Fida Bacha, MD, of Baylor College of Medicine in Houston, Texas, and team shed new light on one of the major public health challenges of the 21st century: the childhood obesity epidemic. While this epidemic is a global problem, reaching across ethnicity and socioeconomic classes, in the United States, Hispanic youth bear a disproportionate burden. According to the U.S. Centers for Disease Control and Prevention, Hispanic children have an obesity prevalence of 26.2%, which is the highest among all racial/ethnic groups.

At Bacha’s laboratory at the Children’s Nutrition Research Center (CNRC) at Baylor, researchers study the risk factors and mechanisms underlying the pathogenesis of the metabolic complications related to childhood obesity and insulin resistance. Among their latest discoveries is a potentially devastating long-term consequence of these intertwining conditions —compromised bone development during the adolescent years when lifelong skeletal strength is established. While these effects may have gone unnoticed until recently in this population, their implications for long-term health are all too obvious. Impaired skeletal development could mean early osteoporosis in adulthood and increased fracture risk, with all of the associated increased morbidity and mortality that carries.

Growing Bodies of Evidence

Bacha’s latest research builds on her team’s previous work published in 2022 in The Journal of Clinical Endocrinology & Metabolism. In “Adiposity, Insulin Resistance, Cardiorespiratory Fitness, and Bone Health in Hispanic Children,” they demonstrated the striking finding that insulin resistance seems to be a culprit mediating the negative relationship between fat mass and bone mass. “While adults with type 2 diabetes are known to have increased risk of fractures, this has not been investigated in youth with type 2 diabetes,” Bacha explains. “We wanted to understand how childhood obesity and early type 2 diabetes affect bone health as children grow.”

Although that study was partly undertaken to fill a gap in the existing literature that had focused thus far on adults, it also served to debunk a prevalent myth. Higher body weight was thought to contribute to osteogenesis in children, given the increased mechanical loading on bones; however, other factors were found to disrupt that process, namely the compounding effects of adiposity and insulin resistance. The current research, says Bacha, is a “logical extension” of that work. “We know childhood obesity is associated with insulin resistance, and children with type 2 diabetes have the severe phenotype. Regarding the comorbidities and complications related to childhood obesity and type 2 diabetes, the skeletal system is another target organ that could be impaired.”

For the current study, partially funded by both the U.S. Department of Agriculture and the National Institutes of Health, the team followed 48 teenagers (average age 15.5 years) for one year. Of the cohort, 27% had normal weight, 31% were classified as overweight with normal blood glucose levels, and 42% had overweight with impaired blood glucose control, including prediabetes (four teens) and type 2 diabetes (16 teens). Researchers measured participants’ adiposity, fitness level, and glucose and insulin levels, along with detailed bone structure and strength assessments of the lower leg (tibia) and forearm (radius). “Although not a lot of work had been done previously on the effect of obesity on the skeletal system, our study published in JCEM showed that insulin resistance does contribute to the relationship between obesity and whole body bone mineral content. Here, we took it a step further to look more into the microarchitecture using high-resolution peripheral quantitative CT,” Bacha says.

“Although not a lot of work had been done previously on the effect of obesity on the skeletal system, our study published in JCEM showed that insulin resistance does contribute to the relationship between obesity and whole-body bone mineral content. Here, we took it a step further to look more into the microarchitecture using high-resolution peripheral quantitative CT.” — Fida Bacha, MD, professor of pediatrics, Children’s Nutrition Research Center, Baylor College of Medicine; professor of pediatrics, Pediatric Endocrinology and Diabetes, Texas Children’s Hospital, Houston, Texas

Bacha explains that the study findings supported their ongoing hypothesis that teens with obesity, especially those with type 2 diabetes, showed less improvement in upper and lower extremity bone strength and quality over time compared to adolescents of normal weight, and, again, that insulin resistance seemed to correlate with less increase in bone strength. Details of this research are soon to be published.

Adolescence and Bone Development

These findings carry particular significance given the nature of adolescent bone development. The teenage years represent the most important period for building lifelong bone strength, with approximately 40% of peak bone mass accrued during adolescence. Bone mass in childhood is likewise known to be a strong predictor of bone status in early adulthood. This makes any interference with bone development during this period especially concerning for long-term skeletal health. From their prior research, Bacha and team are aware of the particular vulnerability of the pubertal population, in whom the negative relationship between obesity and bone outcomes was more pronounced compared to prepubertal youth, again deepening concern about this critical window for bone mass accumulation.

“We see insulin resistance playing a role, but we also need to look further into hyperglycemia,” Bacha explained, regarding the underlying mechanisms. “We studied a relatively small number of children with type 2 diabetes and across a very narrow range of hyperglycemia, so we really need to study a larger number of children across the glycemia spectrum to understand better the effect of hyperglycemia on these relationships,” she says.

The research suggests that the negative effects of obesity on bone health are not simply due to excess weight but rather involve complex metabolic pathways. Insulin resistance, and potentially also hyperglycemia, appear to disrupt normal bone metabolism, potentially affecting both bone formation and resorption processes. This metabolic interference may undermine potential benefits from increased mechanical loading.

Future Research

Bacha’s research program continues to evolve, with several important directions for continuing investigation. “We hope that our future studies will try to also uncover the effects of different therapeutics and what ages may be more susceptible to the adverse effects of diabetes on bone,” she explains. The team also sees the need to expand their work to include larger numbers of children across a broader range of glycemic control, which could provide more definitive answers about the relationship between hyperglycemia and bone health.

Future research will also need to extend follow-up periods to better understand the long-term skeletal consequences of adolescent metabolic dysfunction. In addition to establishing clearer causal mechanisms and exploring therapeutic interventions on bone outcomes, they hope to undertake comparative analyses between adult and adolescent populations.

What We Can Do Now

While definitive answers to pathophysiology and management questions are being sought, lifestyle changes are an important intervention clinicians can counsel patients to make. Said Bacha: “One of the things our previous results showed in terms of the relationship of obesity to whole body bone mineral content is that having better cardiorespiratory fitness would be protective and counter the effect of insulin resistance.” In that study, youths with higher cardiorespiratory fitness showed better bone outcomes, independent of their weight status.

“So, what we would advocate for clinicians to understand,” Bacha continues, “is that the skeletal system could be negatively affected and that we should emphasize the importance of optimizing nutrition to reduce weight but also increase physical activity.”

The team’s research contributes to a growing body of evidence that pediatric obesity affects multiple organ system, with consequences that extend far into adulthood. The skeletal implications add another layer of urgency to obesity prevention and treatment efforts in youth. The findings also highlight the importance of early intervention. Given that peak bone mass is largely determined during the first two decades of life, any compromise in bone development during childhood and adolescence can have lifelong consequences for fracture risk and osteoporosis development.

“We know childhood obesity is associated with insulin resistance, and children with type 2 diabetes have the severe phenotype. Regarding the comorbidities and complications related to childhood obesity and type 2 diabetes, the skeletal system is another target organ that could be impaired.”  — Fida Bacha, MD, professor of pediatrics, Children’s Nutrition Research Center, Baylor College of Medicine; professor of pediatrics, Pediatric Endocrinology and Diabetes, Texas Children’s Hospital, Houston, Texas

Bacha says the research was well received at ENDO and that she fielded lots of great questions from the audience. “I appreciate the interest in our work,” Bacha says, “and I think we are hoping that we raise awareness about this issue and advance the science related to bone health in childhood. Obesity and type 2 diabetes affect the whole body system and bone health is yet another aspect that we’re uncovering that is really important.”

More will be revealed in their upcoming manuscript, but Bacha and team have given us lots to think about in the meantime about how to make care more comprehensive and reaching vulnerable populations.

Horvath is a freelance writer based in Baltimore, Md. In the October issue, she wrote about the historical perspective of Human Growth Hormone and protein-misfolding diseases.