The association between AST/ALT (De Ritis) ratio and osteoporosis or bone mineral density in middle-aged and older adults: A cross-sectional analysis of NHANES data

Osteoporosis (OP), a metabolic bone disease characterized by low bone mineral density (BMD), has an underexplored link with the De Ritis ratio (aspartate aminotransferase/alanine aminotransferase) – a marker of metabolic and inflammatory status. This study investigated the association between the De Ritis ratio and both OP and BMD in middle-aged and older adults. BMD was assessed by dual-energy X-ray absorptiometry, and OP was diagnosed based on a T -score ≤−2.5. First, multivariate logistic regression was employed to estimate the adjusted odds ratio (95% confidence interval) for OP in relation to the De Ritis ratio, with covariates including age, sex, body mass index (BMI), hypertension, diabetes, parental OP history, and key liver markers. Second, multivariable linear regression analyzed the association between the De Ritis ratio and BMD, adjusting for age, sex, and BMI. Finally, the predictive ability of the De Ritis ratio was assessed via receiver operating characteristic curve analysis, with results expressed as the area under the curve. In 2483 subjects (233 OP cases, 9.39%), a higher De Ritis ratio was closely associated with a greater risk of OP after full adjustment. Subgroup analyses asserted this positive association in females, individuals with a BMI < 30 kg/m ² , individuals without hypertension/diabetes/parental OP, and individuals across liver marker subgroups. The multivariable linear regression suggested that participants in the highest De Ritis ratio tertile (T3) had significantly lower BMD at the total femur (β = −0.062, P  = .002; P -trend = .002) and femoral neck (β = −0.049, P  = .025; P -trend = .018) than those in the lowest tertile (T1). Stratified analyses consistently revealed negative correlations between the De Ritis ratio and BMD at both sites. The De Ritis ratio provided an area under the curve value of 0.644 (95% confidence interval = 0.606–0.681) for OP in middle-aged and older adults. Our findings indicate that a higher De Ritis ratio is significantly associated with an increased risk of OP and lower BMD in middle-aged and older adults, suggesting its potential utility as a useful adjunct clinical tool for OP risk stratification. However, the complex relationship underlying this association warrants further validation in large-scale prospective studies.