The hidden fragility: Unmasking the systematic link between lean metabolic dysfunction‐associated fatty liver disease and osteoporosis

Metabolic dysfunction-associated fatty liver disease (MAFLD), as redefined by international consensus in 2020,1 represents a paradigm shift in hepatology. By moving away from a diagnosis of exclusion and instead anchoring the definition in metabolic dysfunction, MAFLD is now recognized as a systemic disorder with multisystem consequences. This reconceptualization has expanded clinical attention beyond hepatic steatosis and fibrosis to include extrahepatic complications such as cardiovascular disease, chronic kidney disease, and malignancy. Increasingly, skeletal health has emerged as another important, yet underappreciated, domain affected by metabolic liver disease. Osteoporosis, characterized by reduced bone mineral density (BMD) and increased fracture risk, may represent a hidden fragility within the MAFLD population, particularly among individuals who do not appear overtly obese. There is growing evidence that supports a connection between MAFLD and osteoporosis. Wang et al.2 demonstrated that patients with lean or normal-weight MAFLD (body mass index [BMI]