Objective: To evaluate whether continuous glucose monitoring (CGM) could assist providers in intensifying glycemic management in hospitalized patients with type 2 diabetes. Research Design and Methods: At 6 academic hospitals, adults with type 2 diabetes hospitalized in a non-intensive care setting were randomly assigned to either standard therapy with a glucose target of 140-180 mg/dL (Standard group) or intensive therapy with glucose target of 90-130 mg/dL guided by CGM (Intensive group). The primary outcome was mean glucose measured with CGM (blinded in Standard group) and the key secondary outcome was CGM glucose <54 mg/dL. Results: Of the 110 participants included in the primary analysis, mean age was 61± 12 years and mean HbA1c was 8.9 ± 2.3% (73.8 ± 1.6 mmol/mol). During the study, CGM-measured mean glucose was 170 mg/dL in the Intensive group (N=60) versus 175 mg/dL in the Standard group (N=50, risk-adjusted difference -7 mg/dL; 95% confidence interval -19 to +5; p = 0.25). Only 7% of the Intensive group achieved the mean glucose target range of 90 to 130 mg/dL. CGM readings below 54 mg/dL were infrequent (0.2% for Intensive and 0.4% for Standard; adjusted treatment group difference = -0.1%, 95% CI -0.6% to 0.3%). One severe hypoglycemia event occurred in the Standard group. Conclusions: The study’s glucose management approach using CGM did not improve glucose levels compared with standard glucose management in the non-ICU hospital setting. A glucose target of 90-130 mg/dL may not be realistic in the current environment of insulin management in the hospital.

Clinical practice variability exists regarding the use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) in kidney transplant recipients (KTRs). The objective of this study was to understand prescribing practices and barriers for the use of SGLT2i and GLP-1RA among endocrinology and nephrology prescribers caring for KTRs. A 19-item electronic survey assessing prescribing practices and barriers for the use of SGLT2i and GLP-1RA in adult KTRs was distributed to all members of the Planning Research in Inpatient Diabetes/Planning Research in Outpatient Diabetes (PRIDE/PROUD) group and the American Society of Transplantation Kidney Pancreas Community of Practice via email listservs between July and November 2023. Endocrinology and nephrology prescribers caring for adult KTRs with type 2 diabetes mellitus (T2DM) or post-transplant diabetes mellitus (PTDM) were eligible. A total of 50 responses were included for analysis (n = 25 endocrinology, n = 25 nephrology). Respondents prescribed SGLT2i and GLP-1RA to adult KTRs with T2DM/PTDM with the following frequency: always (4% SGLT2i, 6% GLP-1RA), often (34% SGLT2i, 30% GLP-1RA), sometimes (34% SGLT2i, 36% GLP-1RA), rarely (22% SGLT2i, 20% GLP-1RA), or never (6% SGLT2i, 8% GLP-1RA). The most common indication for both drug classes was diabetes mellitus (DM)/hyperglycemia (84% SGLT2i, 90% GLP-1RA). Most prescribers felt comfortable initiating a SGLT2i (58%) or GLP-1RA (62%) between 1 and 6 months post-transplant. Prescribers were always or often concerned about infection (67%) with the use of SGLT2i and gastrointestinal intolerance (66%) with GLP-1RA. Cost of treatment/insurance coverage/need for prior authorization and patient concern for drug cost was identified as being very likely or likely barriers for prescribing these drug classes post-transplant (54% SGLT2i, 62% GLP-1RA). SGLT2i and GLP-1RA are prescribed mainly for DM/hyperglycemia by endocrinology and nephrology prescribers between 1 and 6 months postkidney transplant. Concerns surrounding medication access and cost were the most frequently reported barriers to use.

Objective: Despite increased awareness, osteoporosis screening rates remain low. The objective of this survey study was to identify physician-reported barriers to osteoporosis screening.Methods: We conducted a survey of 600 physician members of the Endocrine Society, American Academy of Family Practice, and American Geriatrics Society. The respondents were asked to rate barriers to osteoporosis screening in their patients. We performed multivariable logistic regression analyses to determine correlates with the most commonly reported barriers.Results: Of 566 response-eligible physicians, 359 completed the survey (response rate, 63%). The most commonly reported barriers to osteoporosis screening included patient nonadherence (63%), physician concern about cost (56%), clinic visit time constraints (51%), low on the priority list (45%), and patient concern about cost (43%). Patient nonadherence as a barrier was correlated with physicians in academic tertiary centers (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.06-5.13), whereas clinic visit time constraints were correlated with physicians in both community-based academic affiliates and academic tertiary care ([OR, 1.96; 95% CI, 1.10-3.50] and [OR, 2.48; 95% CI, 1.22-5.07], respectively). Geriatricians (OR, 0.40; 95% CI, 0.21-0.76) and physicians with >10 years in practice were less likely to report clinic visit time constraints as a barrier (11-20 years: OR, 0.41; 95% CI, 0.20-0.85; >20 years: OR, 0.32; 95% CI, 0.16-0.65). Physicians with more patient-facing time (3-5 compared with 0.5-2 d/wk) were more likely to place screening low on the priority list (OR, 2.66; 95% CI, 1.34-5.29).Conclusion: Understanding barriers to osteoporosis screening is vital in developing strategies to improve osteoporosis care.& COPY; 2023 AACE. Published by Elsevier Inc. All rights reserved.

Objective: The safety of SGLT2 inhibitor (SGLT2I) use in patients receiving heart transplants is unknown. We aimed to evaluate key measures of safety after initiation of SGLT2I in a cohort of heart transplant recipients. Methods: Patients in the University of Colorado Health system who received a heart transplant between 1991 and 2022 were included if an SGLT2I was prescribed post-transplant and continued for at least 1 month. Number of urinary tract infections (UTI), urogenital yeast infections (UGI), and ED visits and hospital admissions for skin and soft tissue infections (SSTI) and euglycemic DKA (eDKA) were collected by chart review for the duration of SGLT2I use. Vital signs and lab values were collected at baseline, 3 months, and 6 months after SGLT2I initiation. Least squared means and mean differences were extracted from a random intercept mixed model with an unstructured covariance matrix for each variable. Results: Forty-six (46) patients met criteria for analysis. Mean age was 56.1 years, 80.4% had DM, and 84.8% had CKD at the time of SGLT2I initiation. Mean time on SGLT2I was 15 months (range 1-91 months). Three patients (6.5%) developed UTI and one developed UGI. Three (6.5%) had ED visits and admissions for SSTI: 1 had a post-surgical scalp infection and 2 had lower extremity cellulitis (1 led to hallux gangrene and amputation). No patients developed eDKA. Seven patients (15.2%) discontinued their SGLT2I: 2 for UTI and 1 each for hypotension, cost, fatigue, dialysis, and unspecified. Thirty-six (36) patients with adequate data over time were included in the analysis to assess change in vital signs and labs. There were no statistically significant changes from baseline to 3 months or 6 months after SGTL2I initiation for weight, BMI, SBP, DBP, Cr, eGFR, serum Na or serum K. Conclusions: In this sample of heart transplant recipients on SGLT2I, there were few urogenital and SSTI infections, no eDKA, and no significant change in renal function or electrolytes, which adds support for the safety of SGLT2I in this population. Disclosure S.Zahalka: None. C.C.Low wang: Research Support; Dexcom, Inc., Virta Health Corp., CellResearch Corporation. P.Choksi: None. H.M.Lawler: None. L.Grau: None. T.Jensen: Other Relationship; Somalogic.

Uncontrolled type 2 diabetes mellitus (T2DM) and post-transplant diabetes mellitus (PTDM) increase morbidity and mortality after kidney transplantation. Conventional strategies for diabetes management in this population include metformin, sulfonylureas, meglitinides and insulin. Limitations with these agents, as well as promising new antihyperglycemic agents, create a need and opportunity to explore additional options for transplant diabetes pharmacotherapy. Novel agents including sodium glucose co-transporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP1RA), and dipeptidyl peptidase IV inhibitors (DPP4i) demonstrate great promise for T2DM management in the non-transplant population. Moreover, many of these agents possess renoprotective, cardiovascular, and/or weight loss benefits in addition to improved glucose control while having reduced risk of hypoglycemia compared with certain other conventional agents. This comprehensive review examines available literature evaluating the use of novel antihyperglycemic agents in kidney transplant recipients (KTR) with T2DM or PTDM. Formal grading of recommendations assessment, development, and evaluation (GRADE) system recommendations are provided to guide incorporation of these agents into post-transplant care. Available literature was evaluated to address the clinical questions of which agents provide greatest short- and long-term benefits, timing of novel antihyperglycemic therapy initiation after transplant, monitoring parameters for these antihyperglycemic agents, and concomitant antihyperglycemic agent and immunosuppression regimen management. Current experience with novel antihyperglycemic agents is primarily limited to single-center retrospective studies and case series. With ongoing use and increasing comfort, further and more robust research promises greater understanding of the role of these agents and place in therapy for kidney transplant recipients.

Abstract Background COVID-19 vaccination has resulted in several unexplained side effects. However, thyroiditis has not been commonly reported. Clinical Case A 46- year-old woman without notable past medical history presented with new neck tenderness that began five days after the 1st Pfizer COVID vaccine. Symptoms progressed to nightsweats, heat intolerance, palpitations, mild tremors and fever of 101 F. Her neck tenderness was 4 out of 10 with muscle stiffness and 3 lb weight loss after receiving the vaccine. She took NSAIDS for fever every 12-24 hours. She denied any compressive symptoms, visual symptoms or sleep disturbances. She had no cough, sore throat or close contact with a COVID positive individual/sick contact. RT-PCR was done for COVID-19 and was negative. There was no personal history of radiation exposure or family history of Graves’ disease. There was no prior history of drug allergies. On examination, she was afebrile. Right thyroid gland was visible and tender to touch without overlying redness. A right thyroid nodule was appreciated without discrete margins and was not fluctuant. Left lobe was palpable without any nodules. She was tachycardic and had fine tremors on her hands. The remaining of the exam was unremarkable. Laboratory data showed TSH 0.01 mIU/L (0.3-5.50) with elevated FT4 of 3.05 ng/dL (0.76-1.70) and FT3 of 10.5 pg/mL (1.9-3.9). CBC showed a mild anemia with normal white blood cell count. ESR was elevated. TPO antibodies, thyroglobulin antibodies and Thyroid stimulating Immunoglobulins (TSI) were unremarkable but thyroglobulin level was significantly elevated at 1132 ng/mL (0-35). Thyroid scan demonstrated thyroiditis. Neck US showed diffusely heterogenous thyroid gland with asymmetric enlargement of the right lobe and isthmus and a new right exophytic thyroid nodule measuring 0.6×1.0×1.2 cm. Vascularity was not increased. Several non-enlarged lymph nodes were noted as well. Beta blockers was started in addition to NSAIDs. Neck tenderness resolved within 2 weeks. She received her second dose of COVID-19 vaccine as scheduled. Within 2 months of the initial presentation, thyroid functions normalized. Four months from the initial presentation, symptoms of mild hypothyroidism were noted with a TSH of 5.88. Levothyroxine 50 mcg daily was initiated. Repeat thyroid labs were normal. Follow up thyroid US showed resolution of the right exophytic thyroid nodule, and atrophic thyroid gland. She has remained on levothyroxine replacement with biochemical and clinical euthyroidism. Conclusion Clinicians should be aware of thyroiditis as rare side effect of COVID-19 vaccine on thyroid gland. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Background Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome that presents with hypophosphatemia, bone pain, muscle weakness and fractures. We report a case series of four patients with TIO that resulted in significant muscle weakness and multiple atraumatic fractures. Case presentation Four patients were referred to an endocrinology clinic for the evaluation of multiple atraumatic fractures, muscle weakness, generalized muscle and joint pain. Laboratory evaluation was notable for persistent hypophosphatemia due to urinary phosphate wasting, low to low-normal 1,25-dihydroxyvitamin D, elevated alkaline phosphatase and elevated fibroblast growth factor 23 (FGF23). Tumor localization was successful, and all four patients underwent resection of phosphaturic mesenchymal tumors. Post-operatively, patients exhibited normalization of serum phosphorus, in addition to significant improvement in their ambulatory function. Conclusion Hypophosphatemia with elevated FGF23 and low 1,25-dihydroxyvitamin D level in the setting of multiple atraumatic fractures necessitates careful evaluation for biochemical evidence of tumor-induced osteomalacia.

A novel Coronavirus, SARS-CoV-2 (COVID-19) is now at global pandemic levels causing significant morbidity and mortality. Patients with diabetes are particularly vulnerable and more likely to get severe complications when infected with this virus. Although the information continues to emerge, here we provide our perspective on initial outcomes observed in hospitalized patients with diabetes and the potential role played by the pro inflammatory metabolic state in these patients that promotes fertile ground for the virus’ inflammatory surge, resulting in severe insulin resistance and severe hyperglycemia. The rapidly evolving renal failure, hypotension, pressor and steroid use, and variable nutritional support further complicates their management. Thus, timely implementation of glucose management protocols addressing these complex scenarios while also following COVID-19 related trajectories in inflammatory biomarkers and are cognizant of the health care provider exposure may substantially affect morbidity and mortality.

Almost all patients with diabetes mellitus need glucose-lowering medications (GLMs) plus diet and exercise therapy to achieve good glycemic control. There are 13 classes of GLMs for pharmacotherapy (insulins, insulin analogs, sulfonylureas, meglitinides, thiazolidinediones, biguanides, sodium glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, α-glucosidase inhibitors, amylin analog, dopamine D2 receptor agonist, and bile acid sequestrant) in patients with diabetes. All GLMs improve glycemic control in patients with type 2 diabetes; some may have cardiovascular and renal benefits. Some may also impact bone health in patients who take them. In this chapter, we reviewed the preclinical and clinical studies of each of the 13 GLM classes used by patients with diabetes to categorize its impact on bone health as negative, apparent negative, possible positive, probable neutral, and incomplete information groups. Based on preclinical and clinical evidence, thiazolidinediones have negative impact on bone health and fracture risk.

Objective: To understand osteoporosis screening practices, particularly in men, by a diverse cohort of physicians, including primary care physicians, endocrinologists, and geriatricians. Methods: We surveyed randomly selected members of the American Academy of Family Practice, Endocrine Society, and American Geriatrics Society. Respondents were asked to rate how often they would screen for osteoporosis in four different clinical scenarios by ordering a bone density scan. Multivariable logistic regression analyses were conducted to determine factors associated with offering osteoporosis screening in men in each clinical scenario. Physicians were also asked to note factors that would lead to osteoporosis screening in men. Results: Response rate was 63% (359/566). While 90% respondents reported that they would always or frequently screen for osteoporosis in a 65-year-old postmenopausal woman, only 22% reported they would screen a 74-year-old man with no significant past medical history. Endocrinologists were more likely to screen a 74-year- old man compared to primary care physicians (odds ratio, 2.32; 95% confidence interval, 1.10 to 4.88). In addition to chronic steroid use (94%), history of nontraumatic fractures (88%), and androgen-deprivation therapy for prostate cancer (82%), more than half the physicians reported suppressive doses of thyroid hormone (64%) and history of falls (52%) as factors leading to screening for osteoporosis in men. Conclusion: Our survey results highlight heterogeneity in osteoporosis screening in men, with underscreening in some scenarios compared to women, and identify factors that lead to screening in men. These findings can help design interventions to improve osteoporosis screening in men.

Abstract Introduction: Acquired osteosclerosis due to hepatitis C is a rare complication. While there are previously published case reports of this condition, to our knowledge this is the first case reported with diffusely increased osteosclerosis and prominent bony exostoses. Clinical Case: A 52-year old woman was evaluated in the Metabolic Bone Clinic for non-radiating left hip pain and visibly prominent hard, non-tender masses at the lateral aspect of her bilateral hips and proximal humerus. She denied history of fragility fractures, radiation exposure, risk factors for sexually transmitted diseases or substance abuse. Laboratory evaluation showed vitamin D deficiency with a value of 18 ng/mL (reference range: 25-100 ng/mL), elevated alkaline phosphate of 426 IU/L (reference range: 30-116 IU/L) and markedly increased serum C-telopeptide with a value of 1901 pg/mL (reference range: <1008 pg/mL). Plain radiographs showed multiple exostoses at the pelvis, hip, and shoulders. MRI showed extensive thoracic spine endplate sclerosis and increased sclerosis throughout the pelvis and proximal femurs. Massive calcifications adjacent to the greater trochanters were also identified. A total body bone scan revealed intensely increased uptake in multiple bones consistent with a “super scan.” Bone biopsy showed sclerotic bone with extensive remodeling. Computed tomography of the chest, abdomen, and pelvis was negative for malignancy. Given the symmetric nature of these lesions and diffusely increased uptake, the diagnosis of metabolic bone disease was considered. Further testing revealed hepatitis C Ab positivity confirmed with HCV Quant PCR 1553475 IU/mL (reference range: undetected). Pathologic findings were attributed to hepatitis C and treatment for hepatitis c was initiated with subsequent improvement in alkaline phosphate to 273 IU/L. Clinical Lessons: Osteosclerosis represents a little-known complication of hepatitis C. It is postulated that hepatitis C itself or other unknown agents may stimulate hepatic growth factors that increase osteoblast action. The radiographic and bone scan findings are classic for acquired osteosclerosis seen as increased cortical thickening with an intensely increased uptake in multiple bones. It frequently affects the lower extremity and this condition may take years to develop. Bone formation markers such as alkaline phosphate are typically elevated and bone biopsies show increased rates of remodeling as seen in our patient. While bisphosphonates may improve the serum markers for bone formation, they have not been shown to reverse or halt the progression of skeletal changes. Thus far, there has been a single case report showing improvement in sclerosis following treatment for hepatitis C with ribavirin and interferon. Natural history, progression and treatment of this condition have not been well established.

A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) is now at global pandemic levels causing significant morbidity and mortality. Patients with diabetes are particularly vulnerable and more likely to get severe complications when infected with this virus. Although the information continues to emerge, here we provide our perspective on initial outcomes observed in hospitalized patients with diabetes and the potential role played by the proinflammatory metabolic state in these patients that promotes fertile ground for the virus' inflammatory surge, resulting in severe insulin resistance and severe hyperglycemia. The rapidly evolving renal failure, hypotension, pressor and steroid use, and variable nutritional support further complicates their management. Thus, timely implementation of glucose management protocols addressing these complex scenarios while also following COVID-19-related trajectories in inflammatory biomarkers and being cognizant of the health care provider exposure may substantially affect morbidity and mortality.

Osteoporosis in men has recently been recognized as a significant public health issue; yet, it remains undertreated, leaving men vulnerable to early death and disability. Current guidelines by the Endocrine Society recommend treatment for men at high risk for fracture, including those with osteopenia (T-score between −1.0 and −2.5) and a Fracture Risk Assessment Tool (FRAX) score ≥3% for a hip fracture or ≥ 20% for any fracture (1). However, little is known about physician practice patterns regarding osteoporosis treatment in men.

The long-term effect of weight reduction on skeletal health is not well understood. The purpose of this study was to examine the impact of an intensive medical weight loss intervention using very low energy diet (VLED) (~ 800 cal/day) that result in significant changes in body weight, on total body bone mineral density (BMD) over 2 years.

Dual-energy X-ray absorptiometry (DXA) was the first imaging tool widely utilized by clinicians to assess fracture risk, especially in postmenopausal women. The development of DXA nearly coincided with the availability of effective osteoporosis medications. Although osteoporosis in adults is diagnosed based on a T-score equal to or below − 2.5 SD, most individuals who sustain fragility fractures are above this arbitrary cutoff. This incongruity poses a challenge to clinicians to identify patients who may benefit from osteoporosis treatments. DXA scanners generate 2 dimensional images of complex 3 dimensional structures, and report bone density as the quotient of the bone mineral content divided by the bone area. An obvious pitfall of this method is that a larger bone will convey superior strength, but may in fact have the same bone density as a smaller bone. Other imaging modalities are available such as peripheral quantitative CT, but are largely research tools. Current osteoporosis medications increase bone density and reduce fracture risk but the mechanisms of these actions vary. Anti-resorptive medications (bisphosphonates and denosumab) primarily increase endocortical bone by bolstering mineralization of endosteal resorption pits and thereby increase cortical thickness and reduce cortical porosity. Anabolic medications (teriparatide and abaloparatide) increase the periosteal and endosteal perimeters without large changes in cortical thickness resulting in a larger more structurally sound bone. Because of the differences in the mechanisms of the various drugs, there are likely benefits of selecting a treatment based on a patient’s unique bone structure and pattern of bone loss. This review retreats to basic principles in order to advance clinical management of fragility fractures by examining how skeletal biomechanics, size, shape, and ultra-structural properties are the ultimate predictors of bone strength. Accurate measurement of these skeletal parameters through the development of better imaging scanners is critical to advancing fracture risk assessment and informing clinicians on the best treatment strategy. With this information, a “treat to target” approach could be employed to tailor current and future therapies to each patient’s unique skeletal characteristics.

Context Although bone is a common site for tumor metastases, the burden of bone events [bone metastases and skeletal-related events (SREs)] in patients with thyroid cancer is not well known. Objective To measure the prevalence of bone events and their impact on mortality in patients with thyroid cancer. Patients, Design, and Setting We identified patients diagnosed with thyroid cancer between 1991 and 2011 from the linked Surveillance Epidemiology and End Results-Medicare dataset. Multivariable logistic regression was used to identify the risk factors for bone metastases and SREs. We used Cox proportional hazards regressions to assess the impact of these events on mortality, after adjusting for patient and tumor characteristics. Results Of the 30,063 patients with thyroid cancer, 1173 (3.9%) developed bone metastases and 1661 patients (5.5%) developed an SRE. Compared with papillary thyroid cancer, the likelihood of developing bone metastases or an SRE was higher in follicular thyroid cancer [odds ratio (OR), 2.25; 95% confidence interval (CI), 1.85 to 2.74 and OR, 1.40; 95% CI, 1.15 to 1.68, respectively] and medullary thyroid cancer (OR, 2.16; 95% CI, 1.60 to 2.86 and OR, 1.62; 95% CI, 1.23 to 2.11, respectively). The occurrence of a bone event was associated with greater risk of overall and disease-specific mortality [hazard ratio (HR), 2.14; 95% CI, 1.94 to 2.36 and HR, 1.59; 95% CI, 1.48 to 1.71, respectively]. Bone events were a poor prognostic indicator even when compared with patients with other distant metastases (P < 0.001 and P < 0.001 for overall and disease-specific mortality, respectively). Conclusions Bone events in patients with thyroid cancer are a poor prognostic indicator. Patients with follicular and medullary thyroid cancers are at especially high risk for skeletal complications.

The recognition of hereditary causes of primary hyperparathyroidism (pHPT) is important because clinical care and surveillance differ significantly between sporadic and hereditary pHPT. In addition, the increasing number of genetic tests poses a challenge to classify mutations as benign or pathogenic. Functional work-up of variants remains a mainstay to provide evidence for pathogenicity. We describe a 52-year-old male patient with recurrent pHPT since age 35 years. Despite several neck surgeries with complete parathyroidectomy, he experienced persistent pHPT, necessitating repeated surgery for a forearm autotransplant, which finally resulted in unmeasurable parathyroid hormone (PTH) levels. Genetic testing revealed a new CDC73 variant (c.238-8G>A [IVS2-8G>A]), initially classified as a variant of uncertain significance. Parathyroid tissue from the initial surgeries showed loss of heterozygosity. Using an RT-PCR approach, we show that the mutation leads to the use of a cryptic splice site in peripheral mononuclear cells. In addition, a minigene approach confirms the use of the cryptic splice site in a heterologous cell system. The novel c.238-8G>A CDC73 variant activates a cryptic splice site, and the functional data provided justify the classification as a likely pathogenic variant. Our results underscore the importance of functional work-up for variant classification in the absence of other available data, such as presence in disease-specific databases, other syndromic clinical findings, or family history. In addition, the presented case exemplifies the importance to consider a hereditary condition in young patients with pHPT, particularly those with multi-gland involvement. © 2017 American Society for Bone and Mineral Research.

Background and Methods: Obesity is a highly heterogeneous condition, and the link between adiposity distribution profiles and skeletal health is not well understood. This study examined the association between adiposity and bone mineral density (BMD) in a large cohort (5268 individuals) of US adults aged 20-85 years. Results: Body mass index (BMI) and moderate-to-vigorous physical activity were positively associated with BMD. Conversely, abdominal adiposity was negatively associated with BMD, even after adjusting for age, race, BMI, and objectively-measured physical activity. Conclusions: These findings highlight the negative influence of abdominal adiposity on BMD and contradict the notion that excess fat mass is protective for bone health. (C) 2017 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Chronic disease is not just a physical process that affects the body. It has an effect on an individual’s entire psyche and sense of self. As physicians, we are accustomed to assessing and treating patients’ physical needs. We perform the physical exam, administer diagnostic tests, and prescribe treatments aimed at addressing pathology. We forget, however, that this pathology affects a person whose new relationship with their disease brings about changes in their interactions with self and environment. These changes begin to challenge their identity. The Obscured Self is a mixed-media collage created as part of the Family Centered Experience (FCE), a required course at the University of Michigan Medical School. In the FCE, students have the opportunity to learn and explore the humanistic side of medicine through discussions with volunteer patients and their families who are living with chronic illness. The conversations focus on several aspects of living with a chronic disease. Some of the themes explored are the impact on sense of self and family, adjustments to aspirations, lifestyle and employment, coping with stigmas, and establishing an effective patient–doctor relationship. As part of the program, students complete a creative project that reflects some aspect of the patient experience as related during these visits. The projects are depicted in a variety of media such as song, dance, poetry, or a visual art piece such as The Obscured Self. Our project represents the effect chronic disease has on self-identity. We learned from our families that their disease impinged on certain key aspects of their lives, obfuscating the way they saw themselves and the way they were seen by others. The jagged black projections and translucent patchy film represent disease that has obscured self-identity, casting a shadow over all elements of life. Our patients experienced loss as a result of their chronic illness—loss of their lifestyle, their interests, their independence, their relationships with family and friends, and ultimately a loss in their sense of self. At the center of all that was lost lies the most important lesson: What matters is not what disease takes away, but what it leaves behind. While chronic illness interferes with the superficial elements of self-identity, the core of the human spirit, represented in The Obscured Self by the inner red heart, is untouched by disease. Despite the illnesses from which our patients suffer, they remain resilient, hopeful, and loving people. This is the true nature of humanity, unscathed by chronic illness or disease. With this project, we hoped to capture not just what disease takes away from a person but what it reveals about the human spirit.The Obscured SelfAcknowledgments: The authors would like to thank Aki Yao and Marc R. Stephens for photography of the original work, and Dr. Arno Kumagai for helpful discussions and advice.