Objective:

To investigate the association between metabolic dysfunction-associated fatty liver disease (MAFLD) and bone mineral density (BMD) in patients with type 2 diabetes mellitus (T2DM), emphasizing the exploratory nature of the study and exploring whether insulin resistance, as indicated by HOMA-IR, statistically accounts for part of this association.

Key Findings:

• Patients in the MAFLD group had significantly lower BMD T-scores compared to the non-MAFLD group (−1.12 ± 1.16 vs. −0.50 ± 1.07, P < 0.001).
• MAFLD was inversely associated with BMD after adjusting for age, sex, and BMI (β = −0.562, P = 0.003).
• The indirect effect of MAFLD on BMD through HOMA-IR was statistically significant (β = −0.070, 95% CI: −0.142 to −0.015), accounting for 11.4% of the total association.
• FIB-4 was not independently associated with BMD.
• The prevalence of osteopenia/osteoporosis was higher in the MAFLD group (59.0% vs. 33.7%, P = 0.002).

Interpretation:

The study suggests an association between MAFLD and lower BMD in T2DM patients, with a modest indirect effect via HOMA-IR, but these findings should be interpreted as suggestive rather than conclusive.

Limitations:

• Cross-sectional design limits the ability to establish causality.
• Single-center study may affect generalizability.
• Exclusion criteria may limit the applicability of findings to broader populations.

Conclusion:

MAFLD is associated with lower BMD in T2DM patients, with a modest indirect effect through HOMA-IR, but further research is needed to clarify causal relationships, emphasizing the exploratory nature of these findings.