Abdominal Radiology

, Volume 42, Issue 9, pp 2376–2386 | Cite as

Osteoporosis, obesity, and sarcopenia on abdominal CT: a review of epidemiology, diagnostic criteria, and management strategies for the reporting radiologist

  • Timothy É. MurrayEmail author
  • David Williams
  • Michael J. Lee
Pictorial Essay


Abdominal computed tomography (CT) is a widely performed examination, with many indications. Assessment of bone, fat, and muscle on abdominal CT can be performed in a quantitative manner. Published studies have developed diagnostic cutoffs for osteoporosis, obesity, and sarcopenia, which are summarized with pictorial examples. The epidemiological and prognostic significance of these disease states are outlined. Further diagnostic steps and treatment strategies are outlined to inform both the managing clinician and reporting radiologist. This article summarizes an unglamorous yet information-rich field, which is ripe for assessment in the dawning era of personalized medicine, and one in which the radiologist is well placed to add value to patient care.


Osteoporosis Sarcopenia Obesity CT Abdomen 



Computed tomography


Magnetic resonance imaging


Bone mineral density


Dual-energy X-ray absorptiometry


Dual-energy CT


Quantitative CT


Hounsfield unit


Abdominal visceral fat


Body mass index


High-density lipoprotein


Thyroid function tests


Liver function tests


Compliance with ethical standards


No funding was obtained for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Statement of informed consent was not applicable since the manuscript does not contain any patient data.

Supplementary material

Supplementary material 1 (MP4 86329 kb)


  1. 1.
    Wilson JMG, Jungner G (1968) Principles and practice of screening for disease. World Health Organization Public Health PaperGoogle Scholar
  2. 2.
    Pickhardt PJ, Lee LJ, Muñoz del Rio A, et al. (2011) Simultaneous screening for osteoporosis at CT colonography: bone mineral density assessment using MDCT attenuation techniques compared with the DXA reference standard. J Bone Miner Res 26:2194–2203CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Riggs BL, Melton LJ III (1986) Involutional osteoporosis. N Engl J Med 314:1676–1686CrossRefPubMedGoogle Scholar
  4. 4.
    Anderson F (1997) Osteoporosis in men. Int J Clin Pract 52:176–180Google Scholar
  5. 5.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739CrossRefPubMedGoogle Scholar
  6. 6.
    Kanis J, Johnell O, De Laet C, et al. (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382CrossRefPubMedGoogle Scholar
  7. 7.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767CrossRefPubMedGoogle Scholar
  8. 8.
    Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407–413CrossRefPubMedGoogle Scholar
  9. 9.
    Cooper C, Campion G, Melton Iii L (1992) Hip fractures in the elderly: a world-wide projection. Osteoporos Int 2:285–289CrossRefPubMedGoogle Scholar
  10. 10.
    Masi L (2008) Epidemiology of osteoporosis. Clin Cases Miner Bone Metab 5:11–13PubMedPubMedCentralGoogle Scholar
  11. 11.
    Blume SW, Curtis JR (2011) Medical costs of osteoporosis in the elderly Medicare population. Osteoporos Int 22:1835–1844CrossRefPubMedGoogle Scholar
  12. 12.
    Hernlund E, Svedbom A, Ivergård M, et al. (2013) Osteoporosis in the European Union: medical management, epidemiology and economic burden. Arch Osteoporos 8:136CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    How fragile is her future (2000). International Osteoporosis Foundation. Accessed 20 Nov 2016
  14. 14.
    Kanis JA, McCloskey EV, Johansson H, et al. (2008) A reference standard for the description of osteoporosis. Bone 42:467–475CrossRefPubMedGoogle Scholar
  15. 15.
    Faulkner K, Glüer C, Grampp S, Genant H (1993) Cross-calibration of liquid and solid QCT calibration standards: corrections to the UCSF normative data. Osteoporos Int 3:36–42CrossRefPubMedGoogle Scholar
  16. 16.
    Bansal S, Khandelwal N, Rai D, et al. (2011) Comparison between the QCT and the DEXA scanners in the evaluation of BMD in the lumbar spine. J Clin Diagn Res 5:694–699Google Scholar
  17. 17.
    Li N, Li X, Xu L, et al. (2012) Comparison of QCT and DXA: osteoporosis detection rates in postmenopausal women. Int J Endocrinol 2013:895474–895478Google Scholar
  18. 18.
    Image of trabecular bone of the spine by quantitative computed tomography (2017). MindwaysCT Software via Wikimedia under Creative Commons Licence. Accessed 15 Dec 2016
  19. 19.
    Wesarg S, Kafchitsas K, Erdt M, Khan MF (2010) CAD of osteoporosis in vertebrae using dual-energy CT. In: 2010 IEEE 23rd international symposium on computer-based medical systems (CBMS). IEEE, p 358–363Google Scholar
  20. 20.
    Humadi A, Alhadithi RH, Alkudiari SI (2010) Validity of the DEXA diagnosis of involutional osteoporosis in patients with femoral neck fractures. Indian J Orthop 44:73CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Guglielmi G, Muscarella S, Bazzocchi A (2011) Integrated imaging approach to osteoporosis: state-of-the-art review and update. Radiographics 31:1343–1364CrossRefPubMedGoogle Scholar
  22. 22.
    Wesarg S, Kirschner M, Becker M, et al. (2012) Dual-energy CT-based assessment of the trabecular bone in vertebrae. Methods Inf Med 51:398CrossRefPubMedGoogle Scholar
  23. 23.
    Hopper KD, Wang M-P, Kunselman AR (2000) The use of clinical CT for baseline bone density assessment. J Comput Assist Tomogr 24:896–899CrossRefPubMedGoogle Scholar
  24. 24.
    World Health Organisation (2008) FRAX™—fracture risk assessment tool. World Health Organisation, Geneva. Accessed 10 Dec 2016
  25. 25.
    Kanis J, Johnell O, Odén A, Johansson H, McCloskey E (2008) FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19:385–397CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    UpToDate, Kleerekoper M (2017) Screening for osteoporosis. UpToDate, Waltham. Accessed 29 Jan 2017
  27. 27.
    Cosman F, De Beur S, LeBoff M, et al. (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25:2359–2381CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Moyad MA (2003) Osteoporosis: a rapid review of risk factors and screening methods. Urol Oncol Semin Orig Investig 21:375–379CrossRefGoogle Scholar
  29. 29.
    Lee J, Vasikaran S (2012) Current recommendations for laboratory testing and use of bone turnover markers in management of osteoporosis. Ann Lab Med 32:105–112CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Dell R, Greene D (2010) Is osteoporosis disease management cost effective? Curr Osteoporos Rep 8:49–55CrossRefPubMedGoogle Scholar
  31. 31.
    Ross AC, Taylor CL, Yaktine AL, Del Valle HB (2011) Dietary reference intakes for calcium and vitamin D. Washington, DC: National Academies PressGoogle Scholar
  32. 32.
    Tosteson AN, Melton LJ III, Dawson-Hughes B, et al. (2008) Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int 19:437–447CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Williams G, Fruhbeck G (2009) Obesity: science to practice. Chichester: WileyCrossRefGoogle Scholar
  34. 34.
    de Gara C (2015) Bariatric revision surgery: the cost of doing business. Can J Diabetes 39:S7CrossRefGoogle Scholar
  35. 35.
    Le NTT, Robinson J, Lewis SJ (2015) Obese patients and radiography literature: What do we know about a big issue? J Med Radiat Sci 62:132–141CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Kaul S, Rothney MP, Peters DM, et al. (2012) Dual-energy X-ray absorptiometry for quantification of visceral fat. Obesity 20:1313–1318CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Bouchard C (2007) BMI, fat mass, abdominal adiposity and visceral fat: Where is the ‘beef’? Int J Obes 31:1552–1553CrossRefGoogle Scholar
  38. 38.
    Oka R, Kobayashi J, Yagi K, et al. (2008) Reassessment of the cutoff values of waist circumference and visceral fat area for identifying Japanese subjects at risk for the metabolic syndrome. Diabetes Res Clin Pract 79:474–481CrossRefPubMedGoogle Scholar
  39. 39.
    Rankinen T, Kim S, Perusse L, Despres J, Bouchard C (1999) The prediction of abdominal visceral fat level from body composition and anthropometry: ROC analysis. Int J Obes 23:801–809CrossRefGoogle Scholar
  40. 40.
    Cruz RJ Jr, Dew MA, Myaskovsky L, et al. (2013) Objective radiological assessment of body composition in patients with end-stage liver disease: going beyond the BMI. Transplantation 95:617CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Miyatake N, Takanami S, Kawasaki Y, Fujii M (2004) Relationship between visceral fat accumulation and physical fitness in Japanese women. Diabetes Res Clin Pract 64:173–179CrossRefPubMedGoogle Scholar
  42. 42.
    Lamarche B (1993) Effects of diet and physical activity on adiposity and body fat distribution: implications for the prevention of cardiovascular disease. Nutr Res Rev 6:137–159CrossRefPubMedGoogle Scholar
  43. 43.
    Kuk JL, Katzmarzyk PT, Nichaman MZ, et al. (2006) Visceral fat is an independent predictor of all-cause mortality in men. Obesity 14:336–341CrossRefPubMedGoogle Scholar
  44. 44.
    Després J-P (2012) Body fat distribution and risk of cardiovascular disease. Circulation 126:1301–1313CrossRefPubMedGoogle Scholar
  45. 45.
    Balentine CJ, Marshall C, Robinson C, et al. (2010) Validating quantitative obesity measurements in colorectal cancer patients. J Surg Res 164:18–22CrossRefPubMedGoogle Scholar
  46. 46.
    Kaess B, Pedley A, Massaro J, et al. (2012) The ratio of visceral to subcutaneous fat, a metric of body fat distribution, is a unique correlate of cardiometabolic risk. Diabetologia 55:2622–2630CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Saito T, Murata M, Otani T, et al. (2012) Association of subcutaneous and visceral fat mass with serum concentrations of adipokines in subjects with type 2 diabetes mellitus. Endocr J 59:39–45CrossRefPubMedGoogle Scholar
  48. 48.
    El-Serag HB, Hashmi A, Garcia J, et al. (2014) Visceral abdominal obesity measured by CT scan is associated with an increased risk of Barrett’s oesophagus: a case–control study. Gut 63:220–229PubMedGoogle Scholar
  49. 49.
    World Health Organization (1997) Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organisation, Geneva. Accessed 12 Nov 2016
  50. 50.
    Lau DC, Douketis JD, Morrison KM, Hramiak IM, Sharma AMUE (2007) Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. Can Med Assoc J 176:S1–S13CrossRefGoogle Scholar
  51. 51.
    Moyer VA (2012) Screening for and management of obesity in adults: US Preventive Services Task Force recommendation statement. Ann Intern Med 157:373–378PubMedGoogle Scholar
  52. 52.
    Jensen MD, Ryan DH, Apovian CM, et al. (2014) 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. Circulation 129:S102–S138CrossRefPubMedGoogle Scholar
  53. 53.
    UpToDate, Bray G, Perreault L (2016) Obesity in adults: prevalence, screening, and evaluation. UpToDate, Waltham. Accessed 7 Dec 2016
  54. 54.
    Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. (2010) Sarcopenia: European consensus on definition and diagnosis Report of the European Working Group on Sarcopenia in Older People. Age Ageing 39:412–423CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Morley JE, Anker SD, von Haehling S (2014) Prevalence, incidence, and clinical impact of sarcopenia: facts, numbers, and epidemiology—update 2014. J Cachexia, Sarcopenia Muscle 5:253–259CrossRefGoogle Scholar
  56. 56.
    Burton LA, Sumukadas D (2010) Optimal management of sarcopenia. Clin Interv Aging 5:217–228PubMedPubMedCentralGoogle Scholar
  57. 57.
    Beaudart C, Rizzoli R, Bruyère O, Reginster J-Y, Biver E (2014) Sarcopenia: burden and challenges for public health. Arch Public Health 72:45CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Alliance For Aging Research (2011) Aging In Motion - The Facts about Sarcopenia. Alliance For Aging Research, Washington DC. Accessed 10 Nov 2016
  59. 59.
    Janssen I, Shepard DS, Katzmarzyk PT, Roubenoff R (2004) The healthcare costs of sarcopenia in the United States. J Am Geriatr Soc 52:80–85CrossRefPubMedGoogle Scholar
  60. 60.
    Landi F, Cruz-Jentoft AJ, Liperoti R, et al. (2013) Sarcopenia and mortality risk in frail older persons aged 80 years and older: results from ilSIRENTE study. Age Ageing 42:203–209CrossRefPubMedGoogle Scholar
  61. 61.
    Janssen I, Heymsfield SB, Baumgartner RN, Ross R (2000) Estimation of skeletal muscle mass by bioelectrical impedance analysis. J Appl Physiol 89:465–471PubMedGoogle Scholar
  62. 62.
    Muscaritoli M, Anker S, Argiles J, et al. (2010) Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) “cachexia-anorexia in chronic wasting diseases” and “nutrition in geriatrics”. Clin Nutr 29:154–159CrossRefPubMedGoogle Scholar
  63. 63.
    Fielding RA, Vellas B, Evans WJ, et al. (2011) Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International Working Group on Sarcopenia. J Am Med Dir Assoc 12:249–256CrossRefPubMedGoogle Scholar
  64. 64.
    Morley JE, Abbatecola AM, Argiles JM, et al. (2011) Sarcopenia with limited mobility: an international consensus. J Am Med Dir Assoc 12:403–409CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Chen L-K, Liu L-K, Woo J, et al. (2014) Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc 15:95–101CrossRefPubMedGoogle Scholar
  66. 66.
    Peng PD, van Vledder MG, Tsai S, et al. (2011) Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis. HPB 13:439–446CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Martin L, Birdsell L, MacDonald N, et al. (2013) Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol 2012(2045):2722Google Scholar
  68. 68.
    Miller AL, Min LC, Diehl KM, et al. (2014) Analytic morphomics corresponds to functional status in older patients. J Surg Res 192:19–26CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Zarinsefat A, Terjimanian MN, Sheetz KH, et al. (2014) Perioperative changes in trunk musculature and postoperative outcomes. J Surg Res 191:106–112CrossRefPubMedGoogle Scholar
  70. 70.
    Baumgartner RN, Koehler KM, Gallagher D, et al. (1998) Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol 147:755–763CrossRefPubMedGoogle Scholar
  71. 71.
    Prado CM, Lieffers JR, McCargar LJ, et al. (2008) Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol 9:629–635CrossRefPubMedGoogle Scholar
  72. 72.
    Mourtzakis M, Prado CM, Lieffers JR, et al. (2008) A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Appl Physiol Nutr Metab 33:997–1006CrossRefPubMedGoogle Scholar
  73. 73.
    Nishigori T, Okabe H, Tanaka E, et al. (2016) Sarcopenia as a predictor of pulmonary complications after esophagectomy for thoracic esophageal cancer. J Surg Oncol 113:678–684CrossRefPubMedGoogle Scholar
  74. 74.
    Tamandl D, Paireder M, Asari R, et al. (2016) Markers of sarcopenia quantified by computed tomography predict adverse long-term outcome in patients with resected oesophageal or gastro-oesophageal junction cancer. Eur Radiol 26:1359–1367CrossRefPubMedGoogle Scholar
  75. 75.
    Fried LP, Tangen CM, Walston J, et al. (2001) Frailty in older adults evidence for a phenotype. J Gerontol A 56:M146–M157CrossRefGoogle Scholar
  76. 76.
    Morley JE, Malmstrom T, Miller D (2012) A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging 16:601–608CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Malmstrom TK, Morley JE (2013) SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc 14:531–532CrossRefPubMedGoogle Scholar
  78. 78.
    UpToDate, Walston JD (2016) Frailty. UpToDate, Waltham. https://www.uptodate-com/contents/frailty. Accessed 7 Nov 2016
  79. 79.
    Cameron ID, Fairhall N, Langron C, et al. (2013) A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Med 11:1–10CrossRefGoogle Scholar
  80. 80.
    Sayer AA, Robinson SM, Patel HP, et al. (2013) New horizons in the pathogenesis, diagnosis and management of sarcopenia. Age Ageing 42:145–150CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Denison HJ, Cooper C, Sayer AA, Robinson SM (2015) Prevention and optimal management of sarcopenia: a review of combined exercise and nutrition interventions to improve muscle outcomes in older people. Clin Interv Aging 10:859–869PubMedPubMedCentralGoogle Scholar
  82. 82.
    Rosset A, Spadola L, Ratib O (2004) OsiriX: an open-source software for navigating in multidimensional DICOM images. J Digit Imaging 17:205–216CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Jensen B (2009) OsiriX segmentation plugin development. Accessed 22 March 2017

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Timothy É. Murray
    • 1
    Email author
  • David Williams
    • 2
  • Michael J. Lee
    • 1
  1. 1.Department of RadiologyBeaumont HospitalDublinIreland
  2. 2.Department of Geriatric and Stroke MedicineBeaumont HospitalDublinIreland

Personalised recommendations