Chenglong Wang1
Xuelei Zhang2*- 1Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
- 2Department of Ultrasound, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
A Commentary on
Negative association between Body Roundness Index and bone mineral density: insights from NHANES
by Ding, Z., Zhuang, Z., Tang, R., Qu, X., Huang, Z., Sun, M., and Yuan, F. (2024) Front. Nutr. 11:1448938. doi: 10.3389/fnut.2024.1448938
1 Introduction
We read with great interest the article by Ding et al. (1) entitled “Negative association between Body Roundness Index and bone mineral density: insights from NHANES.” In this study, the authors explored the relationship between body roundness index (BRI) and total bone mineral density (BMD) in U.S. adults. BRI, a newer anthropometric measure, has been shown to more comprehensively reflect visceral fat distribution compared to other traditional indices. Unlike other measures, BRI does not include weight in its calculation; instead, it uses waist circumference, height, and a formula to estimate visceral adipose tissue. The authors constructed three weighted multivariate regression models to explore the relationship between BRI and BMD: Model 1 was unadjusted, Model 2 adjusted for key demographic variables, and Model 3 adjusted for all covariates. The key findings demonstrate a notable inverse relationship between BRI and BMD, thus authors concluded that a higher BRI is associated with lower BMD and a potentially greater risk of developing osteoporosis, advocating for the use of BRI as a valuable marker for early intervention. We commend the authors for their rigorous study design and analytical efforts; however, we would like to raise several concerns and offer suggestions for further consideration to help improve their investigations.
2 Adjustment for body mass index
In Model 3, the authors commendably adjusted for a comprehensive set of covariates, including age, gender, race, education level, poverty-to-income ratio, body mass index (BMI), smoking status, alcohol consumption, activity level, high-density lipoprotein cholesterol, total cholesterol, fasting plasma glucose, triglycerides, vitamin D3, phosphorus, total calcium, creatinine, alanine aminotransferase, diabetes status, and arthritis status. However, the inclusion of BMI as a covariate introduces potential multicollinearity due to the overlapping components in BMI and BRI calculations.
As indicated in Table 1 of the original study, there was a significant positive correlation between BRI and BMI, while BMD levels did not vary substantially across different BRI tertiles. Notably, in Models 1 and 2, BRI was consistently positively associated with BMD, but in Model 3, the association was reversed and became negative. This reversal is likely due to the adjustment for BMI, as a recent study found that BRI negatively associated with the prevalence of osteoporosis in a weighted multivariate logistic regression analysis that did not adjust for BMI (2). Notably, collinearity among the variables can lead to inflated standard errors, reversed effects, or non-significant effects. The observed reversal in Model 3 without a notable increase in standard deviations suggests the need for a variance inflation factor analysis. This analysis would help the authors to rule out collinearity between BRI and BMI and clarify why the results of Model 3 differ from those generated by Models 1 and 2. These two studies have reached completely opposite conclusions, which prompted us to reconsider whether BMI adjustment is necessary when investigating the relationship between new anthropometric measures and diseases in the future.
3 Visceral adiposity and osteoporosis
In fact, through direct dual energy X-ray absorptiometry measurements, visceral adiposity is negatively associated with BMD (3–5). Visceral fat is more metabolically active than other types of fat, secreting a variety of cytokines, including inflammatory ones that disrupt bone remodeling processes. The protective role of mechanical load may be diminished by the adjustment of BMI, which could highlight the adverse effects of inflammation on bones. We commend the authors for their detailed discussion of the potential mechanisms through which visceral fat accumulation promotes osteoporosis.
4 Diagnostic ability
The authors suggest using the BRI as a valuable marker for clinically assessing the risk of osteoporosis and for achieving early intervention. However, the diagnostic ability of BRI was not evaluated in the study. We encourage the authors to perform receiver operating characteristic curve analysis to compare the diagnostic ability of BRI with traditional obesity assessment indicators (not limited to BMI) and other novel measures, such as the Weight-adjusted Waist Index (6), A Body Shape Index (7), Abdominal Volume Index (8), Visceral Adiposity Index (9), and Lipid Accumulation Product index (10). Beyond the receiver operating characteristic analysis, incorporating additional metrics such as the net reclassification index would help establish whether BRI provides incremental diagnostic value over traditional measures, thereby highlighting the significance of this study.
5 Discussion
This study provides an innovative exploration of the relationship between BRI and BMD in U.S. adults; however, we believe that the findings should be interpreted with caution. Specifically, we emphasize that when investigating the association between novel anthropometric measures and osteoporosis, it is crucial to consider the potential collinearity with BMI. In addition, longitudinal studies that examine the impact of weight loss or redistribution of body fat on BMD across BRI tertiles would provide valuable insights into causal relationships. We hope that our insights will assist readers in interpreting the findings more effectively and offer additional perspectives for future research.
Author contributions
CW: Conceptualization, Writing – original draft, Writing – review & editing. XZ: Conceptualization, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Acknowledgments
We would like to thank Editage (www.editage.cn) for English language editing.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that no Gen AI was used in the creation of this manuscript.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Ding Z, Zhuang Z, Tang R, Qu X, Huang Z, Sun M, et al. Negative association between Body Roundness Index and bone mineral density: insights from NHANES. Front Nutr. (2024) 11:1448938. doi: 10.3389/fnut.2024.1448938
2. Zhang X, Liang J, Luo H, Zhang H, Xiang J, Guo L, et al. The association between body roundness index and osteoporosis in American adults: analysis from NHANES dataset. Front Nutr. (2024) 11:1461540. doi: 10.3389/fnut.2024.1461540
3. Zhang P, Peterson M, Su GL, Wang SC. Visceral adiposity is negatively associated with bone density and muscle attenuation. Am J Clin Nutr. (2015) 101:337–43. doi: 10.3945/ajcn.113.081778
4. Jain RK, Vokes T. Visceral adipose tissue is negatively associated with bone mineral density in NHANES 2011-2018. J Endocr Soc. (2023) 7:bvad008. doi: 10.1210/jendso/bvad008
5. Zhu K, Hunter M, James A, Lim EM, Cooke BR, Walsh JP. Relationship between visceral adipose tissue and bone mineral density in Australian baby boomers. Osteoporos Int. (2020) 31:2439–48. doi: 10.1007/s00198-020-05556-0
6. Kim KJ, Son S, Kim KJ, Kim SG, Kim NH. Weight-adjusted waist as an integrated index for fat, muscle and bone health in adults. J Cachexia Sarcopenia Muscle. (2023) 14:2196–203. doi: 10.1002/jcsm.13302
7. Zhang M, Hou Y, Ren X, Cai Y, Wang J, Chen O. Association of a body shape index with femur bone mineral density among older adults: NHANES 2007–2018. Arch Osteoporos. (2024) 19:63. doi: 10.1007/s11657-024-01424-0
8. Chen P-J, Lu Y-C, Lu S-N, Liang F-W, Chuang H-Y. Association between osteoporosis and adiposity index reveals nonlinearity among postmenopausal women and linearity among men aged over 50 years. J Epidemiol Glob Health. (2024) 14:1202–18. doi: 10.1007/s44197-024-00275-9
9. Sun A, Hu J, Wang S, Yin F, Liu Z. Association of the visceral adiposity index with femur bone mineral density and osteoporosis among the U.S. older adults from NHANES 2005–2020: a cross-sectional study. Front Endocrinol. (2023) 14:1231527. doi: 10.3389/fendo.2023.1231527
Keywords: body roundness index, bone mineral density, osteoporosis, obesity, NHANES
Citation: Wang C and Zhang X (2025) Commentary: Negative association between Body Roundness Index and bone mineral density: insights from NHANES. Front. Nutr. 12:1555355. doi: 10.3389/fnut.2025.1555355
Received: 04 January 2025; Accepted: 14 March 2025;
Published: 28 March 2025.
Edited by:
Domenico Sergi, University of Ferrara, ItalyReviewed by:
Guanwu Li, Shanghai University of Traditional Chinese Medicine, ChinaShenglong Lin, Mengchao Hepatobiliary Hospital, China
Copyright © 2025 Wang and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Xuelei Zhang, emhhbmd4bDE5OTZAZW56ZW1lZC5jb20=