Metabolic Dysfunction-Associated Steatotic Liver Disease and Bone Mineral Density in Type 2 Diabetes Mellitus: Insights from a Single-Centre Cross-Sectional Study in North India

Dogga Sudhakar^1,2Sumit Rajotiya^2,3*Sourav Debnath^2,3Nishant Jain^1,2Monal Sherekar⁴Shivang Mishra^2,3Anurag Kumar Singh^2,3MAHAVEER SINGH^1,2*Avinash Munshi^1,2Deepak Nathiya^2,3Balvir Singh Tomar^1,2

• ¹National Institute of Medical Sciences & Research, Jaipur, India
• ²NIMS University, Jaipur, India
• ³NIMS Institute of Pharmacy, Jaipur, India
• ⁴Family Medicine consultant, Connect and Heal Primary Care Pvt Ltd., , Karnataka;, Bengaluru, India

Introduction: 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. Methods: 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. Results: 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). Conclusion: This study establishes significant, site-specific associations between MASLD and reduced bone mineral density in type 2 diabetes mellitus patients, particularly affecting trabecular-rich, weight-bearing 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.