Adolescent Body Mass Index, Weight Trajectories to Adulthood, and Osteoporosis Risk

Importance There are limited data regarding adolescent weight among healthy individuals and their trajectory through early adulthood with respect to bone health. Objective To assess the association between adolescent body mass index (BMI) and osteoporosis risk while accounting for BMI change during early adulthood. Design, Setting, and Participants A retrospective population-based cohort study from 1967 to 2019. Participants were Israeli-born adolescents aged 16 to 19 years who were evaluated for military service. Data were analyzed from January 2023 to March 2025. Exposure Weight and height were measured to calculate BMI at adolescence, and additional sociodemographic and medical data were collected. Health status at baseline and incident cancer and diabetes throughout adulthood were strictly controlled. Main Outcomes and Measures Osteoporosis diagnosis until 2022, recorded in the osteoporosis registry of Maccabi Healthcare Services (the second-largest Israeli health care system). Cox proportional hazard models were applied. Adult BMI measurement was available for 74% of the study population and was used to assess the association between adolescence-to-adulthood weight trajectory and incident osteoporosis. Results In this cohort study of 1 083 491 adolescents, 21 497 (4.58%) women and 6929 (1.13%) men were enrolled in the osteoporosis registry during a cumulative follow-up of 19 400 208 person-years (mean [SD] age at follow-up, 23.7 [8.5] years). There was a consistent inverse association between adolescent BMI and osteoporosis risk in adulthood. The crude incidence rate of osteoporosis decreased from 330.2 per 100 000 person-years among those with extreme underweight (<3rd percentile) to 78.9 among those with obesity (≥95th percentile). Adjusted hazard ratios for osteoporosis ranged from 1.88 (95% CI, 1.74–2.04) to 0.83 (95% CI, 0.77–0.89) in women and from 1.82 (95% CI, 1.64–2.01) to 1.04 (95% CI, 0.93–1.16) in men, using normal BMI as the reference. A sex-specific difference in osteoporosis risk was notable, with obesity not showing a protective association in men compared with women. The findings were robust across multiple models and sample restrictions, and the highest risk was observed in individuals who remained underweight from adolescence into adulthood. Conclusions and Relevance In this cohort study, BMI at a young age and its trajectory to adulthood were significantly associated with risk for osteoporosis in adult life.