REVIEW

Effects of Leptin on the Skeleton

Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018

Ian R. Reid,1,2 Paul A Baldock,3 and Jillian Cornish1

1
University of Auckland, Auckland 1132, New Zealand; 2Department of Endocrinology, Auckland District
Health Board, Auckland 1132, New Zealand; and 3Garvan Institute of Medical Research, Sydney, New South
Wales 2010, Australia
ORCiD numbers: 0000-0001-6021-5458 (I. R. Reid).

ABSTRACT Leptin originates in adipocytes, including those in bone marrow, and circulates in concentrations 20 to 90 times higher
than those in the cerebrospinal fluid. It has direct anabolic effects on osteoblasts and chondrocytes, but it also influences bone
indirectly, via the hypothalamus and sympathetic nervous system, via changes in body weight, and via effects on the production of
other hormones (e.g., pituitary). Leptin’s role in bone physiology is determined by the balance of these conflicting effects. Reflecting
this inconsistency, the leptin-deficient mouse has reduced length and bone mineral content of long bones but increased vertebral
trabecular bone. A consistent bone phenotype in human leptin deficiency has not been established. Systemic leptin administration in
animals and humans usually exerts a positive effect on bone mass, and leptin administration into the cerebral ventricles usually
normalizes the bone phenotype in leptin-deficient mice. Reflecting the role of the sympathetic nervous system in mediating the central
catabolic effects of leptin on the skeleton, b-adrenergic agonists and antagonists have major effects on bone in mice, but this is not
consistently seen in humans. The balance of the central and peripheral effects of leptin on bone remains an area of substantial
controversy and might vary between species and according to other factors such as body weight, baseline circulating leptin levels, and
the presence of specific pathologies. In humans, leptin is likely to contribute to the positive relationship observed between adiposity
and bone density, which allows the skeleton to respond appropriately to changes in soft tissue mass. (Endocrine Reviews 39: 938 – 959,
2018)

W hen the adipokine leptin was discovered in

ISSN Print: 0163-769X
ISSN Online: 1945-7189
Printed: in USA
Copyright © 2018
Endocrine Society
Received: 11 October 2017
Accepted: 26 June 2018
First Published Online:
31 August 2018
the s, there was a growing awareness
of the importance of body weight in determining
bone density and risk of fracture. That area of
clinical research has expanded considerably in the
last two decades, with the critical role of fat mass on
bone density becoming established. Body weight is
now an integral part of the routine clinical
evaluation of fracture risk, being used in the major
risk calculators such as FRAX, Garvan, and
QFracture.
The clinical recognition of an important role of
adipose tissue in bone health led to an explora-
tion of the effects of a key adipokine, leptin, on
bone physiology. This literature can be parti-
tioned into studies of the direct effects of leptin on
bone cells and tissue and studies of the indirect
effects on bone of leptin administration into the
central nervous system (CNS). There is apparent
disagreement between these bodies of research,
with leptin being found to be anabolic and
antiresorptive when applied directly to bone cells
and tissue, whereas its central administration
in mice results in substantial bone loss at some
sites. Administration of leptin affects many fac-
tors that can influence bone metabolism, such as
body weight and sex hormone production, which
complicates interpretation of experimental data.
Understanding the fat-bone connection is further
complicated by studies of leptin-deficient animal
models, which have the leptin levels of starvation but
display many other features of obesity. These bodies
of work will be presented to elucidate how these
conflicting effects play out in intact animals and in

938 https://academic.oup.com/edrv doi: 10.1210/er.2017-00226

 REVIEW

ESSENTIAL POINTS
· Leptin originates in adipose tissue, including in bone marrow adipocytes, and acts directly on osteoblasts and
chondrocytes to increase their growth
· Whereas the leptin-deficient mouse (ob/ob) has reduced length and bone mineral content of long bones but increased
trabecular bone volume in the vertebrae, a consistent bone phenotype in human leptin deficiency has not been
established
· Systemic leptin administration in animals and humans almost always exerts a positive effect on bone mass, except when
given in very high dosages, which substantially reduce body weight as a result of leptin’s anorectic effects
··

Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018

Leptin administration into the third cerebral ventricle usually normalizes the bone phenotype in leptin-deficient animals
The balance of the central and peripheral effects of leptin on bone remains an area of controversy and might vary between
species
· In humans, leptin is likely to contribute to the positive relationship observed between adiposity and bone density

human health and disease. To place these descriptions in current understanding of how soft tissue and bone health
the context of human physiology it is useful to review the interact in humans.

Clinical Impact of Soft Tissue on Bone Health
Bone density
Many studies have demonstrated that bone mineral
density (BMD) is positively related to indices of soft
tissue mass, whether these be body weight, body mass
index (BMI), fat mass, or lean mass () (Fig. ). Con-
troversy has existed as to whether fat or lean masses exert
the greater effect on BMD, and that may depend on age,
sex, gonadal status, and habitual exercise levels (). Some
authors have used statistical techniques to tease apart the
interacting effects of fat and lean tissue on BMD. This is
challenging because of their significant intercorrelation
and because of the even stronger correlations between fat
mass and body weight. Entering such strongly inter-
correlated variables as “independent” variables into a
multiple regression analysis violates the assumptions on
which the analysis is based, and nonsense findings can
result (). This is the likely explanation for the finding in
some studies that fat mass is inversely related to BMD.
When entered individually, body weight, lean mass, and
fat mass are consistently positively related to BMD,
providing a mechanism by which the skeleton is able to
adjust to the load it bears. This explanation is consistent
with the fracture data, which also indicate that adiposity is
protective against fracture.
Fracture risk
Epidemiological studies consistently demonstrate that
low body weight is a risk factor for fracture. Meta-
analyses of data from , to , adults in
prospective, population-based cohorts show that total
fractures, osteoporotic fractures, and hip fractures are
all inversely related to BMI in both men and women
(, ) (Fig. ). If fracture risk is adjusted for BMD, the
dependence of risk on BMI is no longer significant for
total fractures and osteoporotic fractures, suggesting
that the effect of BMI is mediated through its effect on
BMD. In contrast, for hip fracture there is a residual
protective effect from high BMI even after adjustment
for BMD, possibly mediated by the shock-absorbing
effect of the adipose tissue over the greater trochanter.
Some studies have related fracture risk to fat and
lean masses separately. The Study of Osteoporotic
Fractures found that both lean mass and fat mass were
inversely related to hip fracture risk (). A French
study observed a % increase in hip fracture risk for
each standard deviation decrease in fat mass but no
effect of lean mass (). A study of Chinese men in
Hong Kong found that the OR for vertebral fracture
was . when the first quartile of fat mass was com-
pared with the fourth quartile, whereas comparisons of
the same quartiles for lean mass produced a non-
significant OR of . (). Thus, the clinical literature
strongly indicates that adiposity is protective against
fracture. However, more recent studies suggest that
this effect may vary across fracture sites and that
fractures of the upper arm and lower leg are more
common in heavier people (, , ). Fall risk or the
skeletal loading at these sites after falls might account
for these apparent inconsistencies.
Leptin Biology
Maintenance of adequate energy stores is a necessity
for survival. Management of these stores entails the
control of short-term energy balance, by matching
food intake to energy use. However, there also exist
long-term considerations in the maintenance of en-
ergy reserves to ensure survival over seasonal changes,
such as altered food availability, requirements for
reproduction, and thermoregulatory changes. Failure
to properly control both short- and long-term energy

doi: 10.1210/er.2017-00226 https://academic.oup.com/edrv 939

REVIEW

Figure 1. Dependence of BMD and fracture risk on BMI in postmenopausal women. The left panel shows the regression relationship
between total hip BMD (in grams per square centimeter) and BMI in 1462 normal postmenopausal women from the Auckland Calcium
Study (1). r is the Pearson correlation coefficient. The right panel shows the relationship between BMI and risk of fracture [hazard ratio
(HR) vs BMI 25 kg/m2] for osteoporotic fracture (solid line) and hip fracture (dashed line), adjusted for age and time since baseline (2).
Data were gathered from prospective cohorts from more than 25 countries; baseline data on BMI were available from 398,610 women
with an average age of 63 (range 20 to 105) years and follow-up of 2.2 million person-years during which 30,280 osteoporotic fractures
(6457 hip fractures) occurred. Left panel, copyright IR Reid, used with permission. Right panel reproduced with permission from
Johansson H, Kanis JA, Oden A, et al. A meta-analysis of the association of fracture risk and BMI in women. J Bone Miner Res 2014; 29 (1):
223-233 (2). [© 2018 Illustration Presentation ENDOCRINE SOCIETY].

Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018

4.0 Osteoporotic
fracture
Hip fracture
Total hip BMD

3.0
1.0

HR
2.0

1.0

0.5 r=0.39 P < 0.001

0
10 20 30 40 50 10 20 30 40 50
BMI (kg/m2) © 2018 Illustration Presentation BMI (kg/m2)
ENDOCRINE SOCIETY

balance can have serious survival and reproductive
consequences. As a result, powerful regulatory path-
ways have evolved to support these fundamental
processes. Given the bodywide control necessary to
coordinate energy balance, it is not surprising that the
brain takes a pivotal role in setting and maintaining
energetic tone and energy reserves, most notably in the
form of fat storage. However, for central control to
operate efficiently, feedback on the energy state of the
body is necessary. In terms of energy reserves, leptin is
the dominant marker of fat reserves, signaling in an
endocrine manner from white adipose tissue to
metabotropic neurons within the hypothalamus and
brainstem, principally to ensure maintenance of suf-
ficient energy stores. However, leptin also signals di-
rectly to numerous other tissues, creating a regulatory
network capable of responding in a dynamic manner
to both starvation and obesity.
The leptin gene was identified . years ago in a
well-characterized genetically obese mouse (). It
codes a peptide of  amino acids that is principally
expressed in white adipose tissue, including that of the
bone marrow (). It has also been demonstrated in
other tissues, including the breast, ovary, placenta,
pituitary, skeletal muscle, stomach, lymphoid tissue,
mesenchymal stem cells, and bone (–). Cir-
culating leptin levels are pulsatile () and show
a circadian rhythm with the nadir in the mid-
afternoon and the peak at midnight. Circulating
leptin levels are directly correlated with body fat
mass but are also rapidly responsive to changes in
calorie intake, falling during starvation (). Women
generally have higher levels than men, even after for fat
mass is controlled for (). This difference suggests
that sex hormones influence leptin secretion, along
with glucocorticoids, catecholamines, insulin, and
cytokines ().
Leptin action is mediated by the long form of the
leptin receptor (LepRb). This is a type I cytokine
receptor of the IL- receptor family [see Flak and
Myers () for a recent review]. It is a single
membrane–spanning receptor with an –amino acid
extracellular domain, a –amino acid transmembrane
domain, and a –amino acid intracellular domain
(). Several short forms of this receptor also exist,
resulting from alternative RNA splicing at the most
C-terminal coding exon, resulting in intracellular
domains of differing length and sequence composition
(). The very short intracellular domains of the short
forms of the receptor render them unable to signal.
As a result, loss of LepRb alone, as in the db/db mouse,
recapitulates the phenotype of the leptin deficient ob/
ob mouse, and restoration of LepRb alone in mice
lacking all leptin receptor isoforms normalizes phys-
iology (). The murine and human receptors are
highly similar in the amino acid sequences of both the
extracellular (% identity) and intracellular domains
(% identity) (). The binding of leptin to this re-
ceptor results in receptor dimerization and activates a
wide variety of signaling pathways including JAK,
STAT, and MAPK (Fig. ). The short isoforms of the
leptin receptor appear to be involved in the transport
of leptin across the blood-brain barrier and do not
have a signaling function ().
Leptin signaling in the hypothalamus
The CNS is an important target for leptin action. The
brain is normally protected from circulatory factors by
the blood-brain barrier; however, in several regions in
the hypothalamus and brainstem, the blood-brain

940 Reid et al Effects of Leptin on the Skeleton Endocrine Reviews, December 2018, 39(6):938–959

barrier is semipermeable. Neurons in these regions are
bathed by circulating factors, such as leptin, and ex-
press leptin receptors, enabling a direct response to
changes in leptin by altering efferent neural outflow
and the secretion of endocrine factors that regulate
peripheral tissues such as the gut, pancreas, gonads,
and bone.
Leptin receptors are highly expressed in the hy-
pothalamus, where signaling has an anorexic effect.
This effect results from activation of neurons in the
arcuate nucleus that produce pro-opiomelanocortin
and cocaine- and amphetamine-regulated transcript
(CART) and from inhibition of orexigenic neurons
that synthesize agouti-related peptide and neuropep-
tide Y (NPY). Signals from the arcuate nucleus, a
region of blood-brain barrier permeability, project to
numerous regions including the paraventricular nu-
cleus, dorsomedial hypothalamus, ventromedial hy-
pothalamus, and lateral hypothalamus. The lateral
hypothalamus also contains neurons expressing
melanin-concentrating hormone, which is decreased
by leptin, resulting in reduced appetite (). Leptin also
acts via the hypothalamus to regulate the sympathetic
nervous system (SNS) to increase energy expenditure
in brown fat by increasing expression of uncoupling
protein  (UCP) (, ). In addition to regulating
energy homeostasis, leptin regulates hypothalamic-
pituitary function, influencing levels of thyroid hor-
mones, growth hormone, cortisol, and sex steroids. All
of these have important effects on the skeleton. These
pathways are summarized in the upper part of Fig. .
Leptin resistance
In obesity, circulating leptin levels are elevated.
However, the counter regulatory effects on appetite
and thermogenesis are not adequate to result in a
healthy body weight. Clinical trials of leptin admin-
istration in obesity have shown little reduction in
weight (), despite the significant effects of leptin in
normal weight or, particularly, leptin-deficient ani-
mals. As a result, obesity is regarded in part as a state of
“leptin resistance.” This resistance involves impaired
transport of leptin across the blood-brain barrier and
progressive inhibition of leptin signaling in the CNS,
particularly in the arcuate nucleus (, ). In mice,
 hours of high-fat feeding is sufficient to reduce hy-
pothalamic responses to leptin (). Resistance has two
components: reduced access of peripheral leptin to its
sites of action in the hypothalamus and an intracellular
signaling defect in leptin-responsive hypothalamic
neurons (). The extent to which resistance occurs in
the osteoblastic leptin receptors remains to be de-
termined. However, leptin resistance adds complexity
to the interpretation of leptin physiology. In a similar
manner to the obesity of leptin-deficient models
being a reflection of inherent starvation responses that
result when leptin signaling is reduced, the maintenance
of obesity in long-term, high-fat-fed models similarly
doi: 10.1210/er.2017-00226
REVIEW
reflects the actions of reduced leptin signaling through
acquired leptin resistance. As a result, both these obese
models (ob/ob and diet-induced obesity) contain aspects
of reduced leptin signaling as occurs in starvation,
which acts to maintain hyperphagia and promote ad-
ipose accrual but might also modify the skeletal re-
sponse to varying degrees.
Leptin in the circulation and cerebrospinal fluid
Although the CNS is a major leptin target, leptin
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
originates in adipose tissue. It is transported intact
from blood into the CNS by a saturable system ().
Leptin levels are much higher in blood than in the
CNS. Caro et al. () reported that leptin concen-
trations in blood are  times higher than those in the
cerebrospinal fluid in people of normal-weight and 
times higher in people with obesity. Thus, consistent
with actions of leptin resistance to reduce leptin
transport across the blood-brain barrier in obesity, the
% increase in circulating leptin concentration in
obesity results in only a % increase in cerebrospinal
fluid leptin levels. Nam et al. () found peripheral
leptin levels  times higher than cerebrospinal fluid
values in normal subjects and  times higher in
Leptin
PTP1B 2 JAK ROCK1
JAK 2 ?
TCPTP AMPK
IRS2
Socs3 Tyr985 PTPN11
SH2B1
Tyr1077 STAT5 PI3K
ERK
Tyr1138 STAT3
Nuclleus
© 2018 Illustration Presentation ENDOCRINE SOCIETY
Figure 2. The signaling form of the leptin receptor, also known as the long form or LepRb. Leptin
binds to the extracellular domain of LepRb, activating the associated Jak2 tyrosine kinase and
promoting the Jak2-mediated phosphorylation of tyrosine residues 985, 1077, and 1138 of LepRb
(numbering is that of the murine receptor). Phosphorylated Tyr985 recruits PTPN11, which
initiates the ERK signaling cascade. Phosphorylated Tyr1077 and Tyr1138 recruit STAT5 and STAT3,
respectively, permitting their trafficking to the nucleus to mediate the control of cognate gene
expression. In addition, mechanisms that limit LepRb signaling have been defined: Socs3, whose
expression is increased by leptin, binds to phosphorylated Tyr985 to blunt LepRb signaling. Also,
the tyrosine phosphatases, PTP1B and TCPTP, dephosphorylate Jak2 or LepRb to terminate LepRb
signaling. In addition, Rho kinase 1, adenosine monophosphate activated protein kinase, insulin
receptor substrate (IRS)2, and SH2B1 have been shown to act downstream of LepRb, although the
mechanisms by which LepRb controls these pathways have yet to be defined. Reproduced with
permission from Flak JN, Myers JMG. Minireview: CNS Mechanisms of Leptin Action. Mol Endocrinol
2016; 30 (1): 3-12. [© 2018 Illustration Presentation ENDOCRINE SOCIETY].
https://academic.oup.com/edrv 941
REVIEW
Figure 3. Signaling pathways by
which leptin interacts with the
hypothalamus and efferent pathways
acting from the hypothalamus to
the skeleton. [© 2018 Illustration
Presentation ENDOCRINE SOCIETY].
obesity, although absolute levels in the CNS were
higher in obese subjects than in nonobese. Therefore,
in normal physiology (as distinct from pharmaco-
logical manipulations such as leptin injections into the
CNS) leptin receptor occupancy is much higher in the
periphery than in the CNS. These differences in cir-
culating and CNS leptin concentrations are reflected in
the dose responses for the central and skeletal effects of
this peptide defined in the elegant studies of Philbrick
et al. (), which are discussed below.
Bone Phenotypes of Animals With Reduced
Leptin Signaling
Reduced leptin signaling can be produced by the
absence of either a functional leptin gene or the gene
for its receptor. The ob/ob mouse is leptin deficient,
and the db/db mouse and the fa/fa rat lack func-
tional leptin receptors. As a result of the absence of a
leptin effect on eating behavior and energy metab-
olism, these animals exhibit hyperphagia, early-onset
severe obesity, insulin resistance, diabetes, and other
942 Reid et al Effects of Leptin on the Skeleton
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
neuroendocrine abnormalities, such as hypogonadism.
The complete lack of leptin signaling is analogous to
extreme starvation and lipodystrophy, and as a re-
sult the phenotypes of the ob/ob and db/db mice
are similarly extreme. The mice are infertile, have
markedly reduced lean mass and brain weight, and
exhibit hypercortisolism, consistent with the stress of
near starvation.
Ducy et al. () can be credited with bringing a
major focus on the influence of leptin on bone with
their description of the leptin-deficient ob/ob mouse.
This analysis focused on the trabecular bone of the
vertebral bodies, where a “high–bone mass phenotype”
was apparent. Trabecular bone volume was doubled in
the spine, but three-point bending of the femur
showed no difference from wild type, indicating that
the changes observed were site specific rather than
generalized. The changes in trabecular bone volume of
the vertebrae were unexpected because these mice
have high circulating glucocorticoid levels and are
hypogonadal. The increase in vertebral bone mass
appeared to be the result of increased bone formation,
approximately doubled, with no change in osteoblast
Endocrine Reviews, December 2018, 39(6):938–959

surface or number. Osteoclast numbers were increased
by #% in ob/ob mice, consistent with the doubling
in deoxypyridinoline excretion observed. Osteoclast
numbers were returned to normal with sex hormone
replacement. These investigators observed essentially
the same phenotype in db/db mice, which are deficient
in the leptin receptor (Table ).
There are now many other descriptions of the
skeletal phenotype of these animals (Table ), and it is
clear that simply characterizing them as having a high
bone mass does not adequately reflect the complexity
of the skeletal response to leptin deficiency. Many
studies show that the long bones of the lower limb are
shorter and have reduced BMD (, , –) (Fig. ).
Steppan et al. () assessed total body BMD and also
found it to be reduced. Hamrick et al. (, ) and
Turner et al. () each studied vertebral and femoral
bone in the same animals. Both confirmed the Ducy
et al. () finding of increased trabecular bone volume
in the spine (although Turner reported reduced bone
formation rates), but both demonstrated a low–bone
mass phenotype in the femur. Hamrick et al. made the
important observation that there is a dramatic increase
in marrow adiposity in the femur of ob/ob mice, which
is not observed in the spine.
In summary, the data in Table  indicate that leptin
is critical to longitudinal skeletal growth and to the
attainment of a normal BMD (–, , , , ,
). Although trabecular bone in the spine is increased
in most studies that measured it (, , ), the
suggestion that leptin has a uniformly negative effect
on the skeleton is not supported by these studies.
Associations of Circulating Leptin With Bone
Indices in Humans
The phenotype of leptin-deficient animals or humans
represents one end of what would be expected to be a
spectrum of leptin effects. Only small numbers of
leptin-deficient humans have been assessed with re-
spect to their skeletal phenotype, and it is important
to note that no consistent abnormalities emerged
(–). If leptin is involved in normal bone meta-
bolism in humans, then variations in leptin levels
within the normal range might be seen to be related to
various bone parameters. Such studies have been
carried out for a variety of bone end points.
Bone density
There is now a substantial literature relating BMD or
bone turnover to circulating leptin levels in cross-
sectional studies in humans. Because both BMD and
leptin concentrations are related to fat mass, it would
be expected that leptin and BMD would be positively
correlated, which is the finding in most studies
(–). This association is sometimes found not to be
independent of body weight or fat mass (, , ),
doi: 10.1210/er.2017-00226
REVIEW
and the close intercorrelation of fat mass and leptin
[r . . ()] means that multiple regression analysis
cannot be used to assess these interrelationships be-
cause these variables are not sufficiently independent
of one another. Failure to observe this caveat can result
in the finding of an inverse relationship between leptin
and BMD (, ). One analysis concluded that leptin
did not mediate the fat-BMD relationship, but it is not
clear that a statistical approach is able to determine the
direction of causation between biological variables,
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
particularly when leptin is so much more dynamic
than either BMD or fat mass (). The positive cor-
relation between circulating leptin and bone mass has
been documented across the lifespan: in neonates (),
children (), adolescents (), premenopausal women
(), postmenopausal women (, , ), and men
(, ). Consistent with these bone density findings,
leptin is reported to be lower in people with fractures
(, ).The Health ABC assessed the relationship
between leptin and both prevalent and incident
fractures in  older adults (). In that study,
prevalent fractures were significantly less common
with higher leptin levels (P = .) in women but not
in men. Incident fractures in women were also reduced
by % and % in the middle and upper leptin tertiles,
respectively, compared with the lower tertile (P ,
.), but these effects were lost after adjustment for
BMI and race. As noted earlier, collinearity between
these variables is a problem in carrying out such
adjustments. Although these associations do not
establish causation, they suggest that, if anything, the
effect of leptin on the human skeleton is a positive
one.
Bone turnover markers
Many groups have examined relationships between
leptin and bone turnover markers. Some studies have
found no relationship (, ). Others report a positive
relationship between circulating leptin and markers of
bone formation (, ) or an inverse relationship of
leptin with bone resorption (, , ). Both the latter
findings would suggest that leptin exerts a positive
effect on bone mass, consistent with the studies of
BMD, but this effect is potentially confounded by the
other effects of fat mass.
PTH and fibroblast growth factor-23
PTH concentrations are directly related to adiposity in
most clinical contexts (, ), and circulating levels of
leptin and PTH are positively related to one another
(). Body weight, fat mass, and leptin levels are higher
in patients with primary hyperparathyroidism (, ),
but leptin levels show no sustained change after cu-
rative parathyroidectomy (, ), suggesting that
PTH is not driving leptin secretion but that possibly
the reverse may be the case. The latter suggestion is
supported by evidence that leptin increases circulating
PTH three to five times in ob/ob mice (, ). Both
https://academic.oup.com/edrv 943
REVIEW

Table 1. Bone Phenotype of Animals With Reduced Leptin Signaling

Study Spine Appendicular

ob/ob Mouse

Ducy et al. 2000 (36) ↑ TBV, ↑↑ bone formation, ↑ osteoclasts Femur: normal strength

Steppan et al. 2000 (37) Femur: ↓ length and BMC

Total body: ↓ bone area, BMC and BMD

Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018

Hamrick et al. 2004 (38) ↑ Vertebral length, ↑ BMC, BMD and TBV, Femur: ↓ length, BMC, BMD, and cortical thickness; ↑↑ marrow adipocytes
↓ cortical thickness, marrow adipocytes normal

Hamrick et al. 2005 (39) ↑↑ Adipocytes, ↓ osteoclasts Total body: ↓ BMC and BMD

Tibia: ↓ bone formation

Kishida et al. 2005 (40) Growth plates: abnormal columnar structure, disorganized collagen fibrils,
↓ type X collagen, ↑ apoptosis, premature mineralization

Baldock et al. 2005 (41) Femur: ↑ TBV, trabecular thickness, mineral apposition rate,
osteoclast surface (all in cancellous bone)

Ealey et al. 2006 (42) Normal BMC, BMD, strength Femur: ↓ BMC, BMD, strength

Iwaniec et al. 2007 (43) ↑ Cancellous bone Femur: ↓ length, total bone volume; ↑ cancellous bone

Turner et al. 2013 (44) ↑ TBV, ↓ bone formation Femur: TBV normal, ↓ bone formation, ↓ linear growth; ↑ bone resorption

Philbrick et al. 2017 (35) Femur: ↓ linear growth, bone formation, trabecular thickness; bone resorption
normal

↓ Bone turnover markers (↓↓ CTX)

db/db Mouse

Lorentzon et al. 1986 (45) Tibia: ↓ length, BMC, BMD, cortical bone

Femur: ↓ TBV

Takeshita et al. 1995 (46) Femur: ↓ length, ash weight and BMD

Ducy et al. 2000 (36) ↑ TBV, ↑ bone formation, ↑ osteoclasts Femur: ↑ trabecular number (data not shown)

Ealey et al. 2006 (42) Normal BMC, BMD, strength Femur: ↓ BMC, BMD, strength

Williams et al. 2011 (47) ↓ Trabecular and cortical thickness Tibia: ↓ TBV, cortical bone
but not volume
Femur: ↓ strength and stiffness

↓ Serum osteocalcin

Turner et al. 2013 (44) ↓ Bone turnover markers

Spine: ↓ bone formation

Femur: ↓ bone formation

fa/fa Rat

Foldes et al. 1992 (48) Femur: shorter and lighter, ↑ cortical width

Mathey et al. 2002 (49) Femur: ↓ BMC, BMD, and strength

Tamasi et al. 2003 (50) Tibia: no change in BMD; ↓ TBV, osteoclast, and osteoid surface

Abbreviations: BMC, bone mineral content; CTX, C-telopeptide of type I collagen; TBV, trabecular bone volume.

leptin and its receptor are expressed in human direct and indirect effects of leptin on bone and of the
parathyroid chief cells, and leptin stimulates PTH leptin-independent effects of obesity on the skeleton,
release in vitro (). Any effects on bone turnover of accounting for the variable relationships between
leptin-driven PTH secretion will be modified by the leptin and turnover markers, described earlier.

944 Reid et al Effects of Leptin on the Skeleton Endocrine Reviews, December 2018, 39(6):938–959

Circulating levels of fibroblast growth factor-
(FGF) are also correlated with adiposity (, ).
Leptin directly stimulates FGF expression in pri-
mary rat osteoblasts (), and administration of leptin
to ob/ob mice almost doubles serum FGF concen-
trations and is associated with reduced renal expres-
sion of a-hydroxylase mRNA and reductions in
circulating ,-hydroxyvitamin D (, ).
Skeletal Effects of Leptin Action in the CNS
After the identification of leptin as a key regulator of
energy homeostasis, work proceeded rapidly to elu-
cidate its mechanism of action. This research identified
the CNS, particularly the hypothalamus, as the key site
of action of leptin. Accordingly, some early work to
determine the actions of leptin on the skeleton focused
on administration of leptin into the CNS. These
studies are summarized in Table .
The first such study was carried out by Ducy et al.
(), who administered intracerebroventricular (ICV)
leptin infusions to ob/ob and wild-type mice. There
was no detectable leak of leptin into the bloodstream.
Trabecular bone volume of the vertebrae was sub-
stantially reduced in both groups to below wild-type
levels by the leptin treatment. Weight change was not
reported. Bone formation was increased in the ob/ob
mouse before treatment (see Table ), but changes in
bone formation were not reported after ICV leptin
treatment, although the authors concluded that “leptin
is a major regulator of bone formation.” Similar
findings in the vertebrae were reported by Iwaniec
et al. (), who gave a single hypothalamic ICV in-
jection of leptin-producing adenoassociated virus to
ob/ob mice, which resulted in normalization of body
weight and recapitulation of the wild-type skeletal
phenotype. Femoral and vertebral cancellous bone
volume were reduced, but femur length and total
femur bone volume were increased to wild-type levels,
reinforcing the antiosteogenic effect of ICV leptin on
cancellous bone but demonstrating anabolic actions
on cortical bone. Turner et al. () also reported the
effect of ICV injection of a leptin-producing construct
on vertebral bone. This treatment restored bone
microarchitecture to normal but was accompanied
by a fourfold increase in osteoblast perimeter in the
spine, indicating that it is an oversimplification to
characterize hypothalamic leptin as simply being
“antiosteogenic” in its skeletal effect. Bartell et al. ()
also showed that ICV leptin increased mineral ap-
position rate in both the vertebra and the tibia,
comparably to the effect of subcutaneously adminis-
tered leptin. They found that expression of genes
associated with osteogenesis was increased in femoral
bone marrow stromal cells after ICV injection;
whereas expression of genes associated with osteo-
clastogenesis, adipogenesis, and adipocyte lipid storage
doi: 10.1210/er.2017-00226
REVIEW
was decreased. They concluded that “ICV injection of
leptin promotes expression of pro-osteogenic factors
in bone marrow, leading to enhanced bone formation
in ob/ob mice” (). The study by Pogoda et al. () is
particularly important because it extends this work
beyond rodent studies. Using adult ewes infused with
leptin ICV for  months at a dosage that did not
reduce body weight, they showed a global reduction in
bone formation, as reflected by circulating bone al-
kaline phosphatase and osteocalcin concentrations,
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
and a reduction in bone formation on histomor-
phometry. Trabecular bone volume was reduced in
the lumbar spine, iliac crest, and distal femur, but
mechanical testing of the tibia was unaffected. Thus,
Table  demonstrates the consistency of evidence that
ICV leptin reduces trabecular bone volume in the
spine and elsewhere, but it is not clear that this is
always caused by reduced bone formation, and effects
on cortical bone are mixed.
The Karsenty group () went on to demonstrate
that the bone and anorexigenic effects of central leptin
treatment were dissociable. In wild-type mice, the
selective destruction of neurons in the ventral hypo-
thalamus by gold thio-glucose increased vertebral
cancellous bone mass, and ICV leptin treatment ( ng/h)
in these animals no longer influenced the cancellous
phenotype, whereas it decreased body weight by %.
Neuropeptides mediating leptin’s anorexigenic function
(a-melanocyte-stimulating hormone, CART) did not
affect bone formation. In parabiosed ob/ob mice, ICV
leptin corrected the skeletal changes in the recipient, with
Figure 4. Contrasting bone phenotypes of the ob/ob mouse
are demonstrated by the reduced length of the femur in the
ob/ob but an increase in trabecular bone volume, shown in the
insets. Body weight is approximately doubled in the ob/ob.
Reproduced with permission from Iwaniec UT, Boghossian S,
Lapke PD, et al. Central leptin gene therapy corrects skeletal
abnormalities in leptin-deficient ob/ob mice. Peptides 2007;
28:0.1012-1019. [© 2018 Illustration Presentation ENDOCRINE
SOCIETY].
https://academic.oup.com/edrv 945
REVIEW
Table 2. Effects of ICV Leptin Administration on Bone in Animals
Study
Leptin-deficient
Ducy et al. (2000) (36)
Iwaniec et al. (2007) (43)
Bartell et al. (2011) (84)
Turner et al. (2013) (44)
Wild-type
Ducy et al. (2000) (36)
Pogoda et al. (2006) (85)
Abbreviations: TBV, trabecular bone volume; WT, wild type.
946
Model Dosing
4-mo-old ovariectomized ob/ob 8 ng/h over 28 d
mice
8- to 10-wk-old male ob/ob mice Single hypothalamic ICV
injection of leptin-producing
adenoassociated virus
15-wk-old female ob/ob mice 0.4 or 1.5 mg/d for 12 d
8- to 10-wk-old male ob/ob mice Single hypothalamic ICV
injection of leptin-producing
adenoassociated virus
4-mo-old female mice 8 ng/h over 28 d
6- to 7-y-old ewes 8 mg/h for 3 mo
no change in the parabiosed animal, ruling out a cir-
culatory factor in the bone effects of central leptin and
suggesting a neuronal mediator.
Mediation of leptin effects on bone via the SNS
Regulation of the SNS by the hypothalamus, and the
known effects of adrenergic agonists on bone, sug-
gested the SNS as a promising candidate for mediating
the central effects of leptin. It was already established
that leptin increases catecholamine secretion, an effect
thought to be mediated by the ventromedial hypo-
thalamus (). Takeda et al. () examined a model
that impairs the SNS by blocking the production
of norepinephrine and epinephrine (dopamine b-
hydrolase deficient mice, Dbh2/2) and reported a similar
but less severe vertebral cancellous bone phenotype to
that of the ob/ob mice. Cortical bone was not assessed.
Cancellous bone in the Dbh2/2 mice was not affected by
central leptin treatment, despite this intervention dra-
matically reducing the weight of the gonadal fat pad.
Thus central leptin could act on bone via the SNS in-
dependently of the pathways that mediate its effects on
body weight. They then demonstrated that systemic
Reid et al Effects of Leptin on the Skeleton
Effects
Spine TBV ↓ from 16.9% to 8.4%
Weight changes not reported
Body weight ↓ 50%
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
↑ Femoral length and total bone volume, ↓ femoral and
vertebral cancellous bone volume 15 wk postinjection
ob/ob mice no longer differed from WT
Body weight ↓, whole body BMD ↑
↑ Osteogenesis in femoral bone marrow stromal cells
↓ Serum insulin and ↑ osteocalcin
Body weight ↓ 50%
Spine: TBV ↓ 50%, osteoblast perimeter ↑ 43
TBV ↓ from 13.2% to 9.4%
Weight changes not reported
Body weight: no change
Tibia: no change in mechanical testing
TBV ↓ in lumbar spine, iliac crest, and distal femur
↓↓ Bone formation rate, bone alkaline phosphatase, and
osteocalcin
treatment with a b-agonist decreased bone mass and
bone formation rate in the tibial and vertebral meta-
physes and that a b-blocker (propranolol) had the op-
posite effect in wild-type mice. Leptin ICV infusion
decreased fat pad weight but not bone mass in b-blocked
wild-type mice. They also found that propranolol could
completely prevent bone loss after ovariectomy in wild-
type mice.
Subsequent studies from the Karsenty group ()
provided further evidence of leptin acting on bone
formation via the SNS and extended this evidence
further to suggest that this pathway also regulated
bone resorption. Mice lacking the b-adrenergic
receptor (Adrb2/2) had increased trabecular bone
volume in both the vertebrae and the distal femur.
Transplantation of wild-type bone marrow cells
into irradiated Adrb2/2 mice reduced bone for-
mation to normal, and, conversely, transplantation of
Adrb2/2 bone marrow cells into irradiated wild-
type mice significantly increased bone formation.
ICV leptin did not affect vertebral cancellous bone in
Adrb2/2 mice, confirming the role of the SNS in
this response.
Endocrine Reviews, December 2018, 39(6):938–959

Bone resorption was also found to be altered by
the leptin-SNS signaling pathway, via central and
peripheral actions (). Leptin deficiency reduces
expression of the neuropeptide CART in the hypo-
thalamus, promoting bone resorption. In bone, local
b-adrenergic receptor signaling increases RANKL
expression from osteoblast progenitor cells, with
RANKL expression lower in Adrb2/2 osteoblasts (,
), whereas the b-adrenergic agonist isoproterenol
increases osteoblast-induced osteoclastogenesis from
bone marrow monocytes. Thus, leptin signaling from
the brain via the SNS acts on osteoblasts to influence
not only bone formation but also RANKL expression
and subsequently osteoclast differentiation and can-
cellous bone resorption. These findings were rein-
forced by a subsequent article from this group
demonstrating that cell-specific deletion of the leptin
receptor in neurons resulted in increases in bone
formation, increases in bone resorption in the verte-
brae, and increased trabecular volume in the spine and
distal tibia (). Additionally, the l/l mice, which have a
gain-of-function mutation in the leptin receptor,
showed upregulation of sympathetic activity and re-
duced spine and tibia trabecular bone volume, al-
though gonadal fat pads were reduced ().
The SNS also mediates leptin’s regulation of lipid
metabolism. Acting through the hypothalamus and
the SNS, leptin inhibits lipogenesis and promotes li-
polysis and fatty acid oxidation in both adipose tissue
and the liver (, ). These effects also occur in bone
marrow adipocytes: direct injection of leptin into the
ventromedial hypothalamus in rats substantially de-
creases the adipocyte population in bone marrow,
primarily through apoptosis (). Thus, the central
actions of leptin are likely to directly affect local bone
cell activity as a result of changes in adipokine and fatty
acid production in marrow adipocytes ().
Effects of adrenergic blockade on bone in humans
As noted earlier, the bone loss in leptin-deficient and
wild-type mice receiving infusions of leptin into the
third ventricle results from inhibition of bone for-
mation () and stimulation of bone resorption ().
Blockade of the SNS abrogates these effects, which
appear to be mediated by b-adrenoreceptors on
osteoblasts (). Drugs that modify the action of the
SNS have been widely used clinically for many years, so
if sympathetic activity has a measurable impact on
bones in humans, this effect should be evident from
epidemiological studies and clinical trials. Many
groups have undertaken such analyses, demonstrating
beneficial (–), null (, ), or detrimental ()
effects of b-blockers on fractures. Among the studies
suggesting apparent benefit, it should be noted that
Yang et al. () found benefit only in those using
selective b-blockers, which should not affect ad-
renergic signaling in osteoblasts (suggesting that this
study should be classified as null in the list above);
doi: 10.1210/er.2017-00226
REVIEW
Rejnmark et al. () found comparable benefit to that
of b-blockers with ACE inhibitors and calcium
channel blockers (suggesting that this effect is related
to hypertension or its treatment rather than b-
blockers per se); and de Vries et al. () found that the
protective effect of b-blockers was present only among
patients with a history of use of other antihypertensive
agents and was not associated with cumulative dose or
receptor selectivity of the b-blockers. Thus, it is likely
that observational studies of the use of b-blockers are
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
confounded by the indications for which these drugs
are prescribed and by other medications that are
commonly coprescribed with them. Also, although
early agents in this class (e.g., propranolol) were
nonselective, b-selective blockers are now more
commonly used and will not affect osteoblasts that
express only the b receptor.
Randomized studies can overcome these potential
confounders in observational data. The many trials
involved in the development of b-blockers as clinical
drugs have not reported reduced fracture numbers,
although these data would have been captured as
adverse events in these studies. To address this
question more formally, we analyzed data pooled from
nine randomized controlled trials of a nonselective
b-blocker (carvedilol) in the management of con-
gestive heart failure (). This patient population was
chosen because it was likely to have a high risk of
fracture. From a total subject population of , .%
of placebo-treated subjects experienced a fracture
compared with .% of those randomized to carvedilol
(relative risk, .; % CI, . to .). This database
does not provide any evidence to support the hy-
pothesis that b-blockers reduce fracture numbers. We
also carried out a prospective randomized controlled
trial of propranolol in normal postmenopausal women
to assess its effects on bone turnover. This study did
not demonstrate stimulation of bone formation, as had
been observed in mice, but found variable declines in
markers of bone turnover, particularly serum osteo-
calcin (). Thus, the human studies do not re-
capitulate the findings in mice, although we do not
have comprehensive dose-response data for selective
and nonselective b-blockers to exclude the possibility
that these agents can affect skeletal mass and fractures.
In light of currently available information, the SNS
does not seem to be a clinically important regulator of
bone metabolism in leptin-sufficient humans.
Leptin and NPY
As mentioned earlier, leptin’s metabolic actions are
mediated in part through regulation of energy
modulatory neuropeptides in the hypothalamus, in-
cluding pro-opiomelanocortin, CART, agouti-related
peptide, and NPY. Along with CART, NPY has been
shown to mediate important aspects of leptin’s action
on bone, with increased expression of NPY in the
hypothalamus in ob/ob mice (). NPY has a strong
https://academic.oup.com/edrv 947
REVIEW
antianabolic influence on cortical and cancellous bone,
and NPY-deficient mice display increases in cancellous
and cortical mass (). Consistent with this action,
dual NPY- and leptin-deficient (NPY2/2ob/ob) mice
display greater whole body, femoral, and vertebral
BMD compared with ob/ob mice (), the result of an
increased cortical bone formation rate correcting the
reductions in BMD of ob/ob mice to wild-type levels,
with minimal effects on body composition ().
Consistent with the segregation of cancellous and
cortical control in ob/ob mice, no changes in cancel-
lous bone were apparent between NPY2/2ob/ob and
ob/ob mice, suggesting that the leptin-NPY pathway to
cortical bone can function independently of the leptin-
adrenergic axis to cancellous bone. Thus the reduction
in cortical bone mass evident in ob/ob mice might be
contributed to by an elevation in central NPY ex-
pression, whereas reduction of adrenergic signaling
produces the increase in cancellous bone volume.
Importantly, this complex, envelope-specific regula-
tion of bone turnover by leptin deficiency is consistent
with the skeletal response to calorie deprivation evi-
dent in wild-type mice (). Consistent with
increased central NPY mimicking a low-leptin/
starvation response, viral-mediated overexpression
of NPY in the hypothalamus led to marked increases
in food intake and in gains white adipose tissue mass;
however, despite this increase in weight, cortical bone
formation was markedly reduced (). Hypothalamic
NPY signaling is an important part of the central
regulation of bone by leptin, most prominently in
cortical bone, reducing bone mass in leptin-deficient
states. Thus the ob/ob mouse may be an accurate
representation of the skeletal response to reduced
leptin signaling, implicating both adrenergic and NPY-
mediated pathways in regulating hypocaloric re-
sponses in bone.
Leptin and serotonin
Serotonin is a monoamine neurotransmitter produced
in the CNS by tryptophan hydroxylase  (Tph) and in
the gastrointestinal tract by Tph (). Because se-
rotonin does not cross the blood-brain barrier, central
serotonergic actions are not influenced by serum se-
rotonin levels. Tph-expressing neurons express the
leptin receptor, and leptin reduces Tph expression
and activity in serotonergic neurons (). Tph2/2
mice display a low bone mass phenotype resulting
from reduced bone formation and increased re-
sorption. Ablation of the leptin receptor on seroto-
nergic neurons produced a high cancellous bone mass
phenotype similar to ob/ob. The phenotypic similarity
suggested a functional link between brainstem neu-
rons and the ventromedial hypothalamus in the
central control of bone mass, reinforced by a high
cancellous bone mass phenotype after deletion of the
serotonin receptor (Htrc2/2) from the ventromedial
hypothalamus in mice. The regulation of appetite is
948 Reid et al Effects of Leptin on the Skeleton
mediated by a pathway from the brainstem to the
arcuate nucleus, via Htra and b serotonin receptors
(). Therefore, centrally leptin appears to exert an
indirect osteogenic action through the suppression of
serotonergic signaling to the ventromedial hypothal-
amus, but efferent pathways are needed for this signal
to be relayed to bone cells. Figure  describes these
pathways.
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
Direct Actions of Leptin on Bone
Receptors
In addition to the CNS-mediated effects of leptin on
bone, discussed earlier, it has become firmly estab-
lished that leptin also acts directly on bone cells. The
signaling form of the leptin receptor has been dem-
onstrated in rat osteoblasts (, ); human oste-
oblasts (, ); human mesenchymal stem cells
undergoing osteogenic () or adipogenic differenti-
ation (); human (), porcine (), and mouse
() chondrocytes; and osteoblastic and chondrocytic
cell lines (, ). There is some evidence that leptin
receptor expression decreases as osteoblast differen-
tiation advances (). In contrast, Ducy et al. ()
reported absence of leptin receptors in primary os-
teoblasts and whole bone. However, the balance of
these results indicates that leptin has the potential to
play a direct role in skeletal physiology, independent of
the CNS. This potential is confirmed by in vitro studies
in skeletal cell and tissue cultures showing that leptin
activates multiple pathways, including Jak/Stat, in
cultured osteoblast lineage cells (–).
Osteoblasts
A consistent body of evidence shows that leptin has a
direct anabolic effect on cells of the osteoblast lineage.
Iwaniec et al. () reported dose-related increases in
the formation of mineralized bone nodules in primary
osteoblast cultures with leptin in concentrations be-
tween  and  ng/mL. These findings were sub-
sequently confirmed by Reseland et al. (). Thomas
et al. () showed that leptin promoted differentiation
of a human marrow stromal cell line into an osteoblast
phenotype, increasing synthesis of the bone matrix
proteins type I collagen and osteocalcin. Differentia-
tion of these cells to adipocytes was diminished by
leptin (). Cornish et al. () demonstrated stim-
ulation of osteoblast proliferation by leptin at physi-
ological concentrations. The maximum stimulation of
cell growth was comparable to that produced by other
major osteoblast mitogens, such as IGF, TGF-b,
epidermal growth factor, and insulin (Fig. ). In
cultures of human iliac crest osteoblasts, Gordeladze
et al. () showed that leptin promoted collagen
synthesis, cell differentiation, and in vitro minerali-
zation, as well as cell survival and transition into
preosteocytes. Gene expression changes with leptin
Endocrine Reviews, December 2018, 39(6):938–959

treatment indicate increased osteoblast differentiation
and mineralization (). An analysis of the human
osteoblast transcriptome concluded that these cells
expressed both leptin and its receptor, that leptin
expression was substantially upregulated by gluco-
corticoid, and that leptin might be an important
autocrine regulator in bone (). In vivo, leptin in-
fusions increase mRNA levels for bone and cartilage
matrix proteins in tibiae of ob/ob mice (). Leptin also
appears to play a role in fracture healing. In ob/ob
mice, one group has reported that maturation of
fracture callus is delayed, and this effect is fully re-
versed with local application of leptin (); another
study has found that ob/ob mice show accelerated
callus formation and remodeling but that the cortex
formed is thinner ().
Turner et al. () used an innovative approach to
establish the local effects of leptin on bone formation.
Wild-type mice were lethally irradiated, and then their
bone marrow was reconstituted with marrow from
either wild-type or db/db mice. Engraftment of db/db
bone marrow did not influence energy homeostasis,
but it reproduced the low rates of bone formation ob-
served in db/db mice. These results indicate that oste-
oblast behavior in vivo is determined by the presence or
absence of the leptin receptor in bone and that the bone
phenotype of the db/db mouse can be recapitulated by
the absence of leptin signaling in bone cells alone.
Osteoclasts
The first suggestion that leptin might locally regulate
bone resorption came from Holloway et al. (),
who demonstrated leptin inhibition of osteoclast
generation in cultures of human peripheral blood
mononuclear cells. Leptin increased osteoprotegerin
mRNA and protein expression in cultures, suggesting
that the inhibitory effect was mediated via the
RANK/osteoprotegerin system. Burguera et al. ()
found that leptin increased osteoprotegerin (a pro-
tein that inhibits osteoclastogenesis) and decreased
RANK ligand levels (the principal regulator of os-
teoclast development) in human marrow stromal
cells. Lamghari et al. () found that leptin reduced
RANKL mRNA and protein in the MCT-E cell
line, and Gordeladze et al. () showed leptin
stimulation of osteoprotegerin in osteoblasts, en-
tirely consistent with the Holloway results. Work by
Cornish et al. () complemented these findings. They
reported reduced osteoclast formation in mouse bone
marrow cultures treated with leptin but no effect of leptin
on the activity of mature osteoclasts, either those isolated
from rats or in neonatal organ culture. Thus, leptin
appears to act on the osteoblast to regulate osteoclas-
togenesis but not on the mature bone resorbing cell.
Other skeletal cells
As noted earlier, chondrocytes have leptin receptors.
Cornish et al. () demonstrated increases in cell
doi: 10.1210/er.2017-00226
REVIEW
number and thymidine incorporation into canine
and ovine chondrocytes after treatment with phys-
iological concentrations of leptin. They also showed
an increase in growth plate thickness after systemic
administration of leptin to normal adult male mice.
Maor et al. () confirmed the presence of leptin
receptors in chondrocytes and demonstrated in or-
gan cultures of mandibular condyles that leptin in-
creased the width of the chondroprogenitor zone,
inducing both proliferation and differentiation of
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
chondrocytes. Leptin also increased the abundance
of the IGF receptor within the chondrocyte and
the progenitor cell populations, suggesting that it
acts synergistically with other growth factors. Gat-
Yablonski et al. () found that leptin increased the
level of PTH-related peptide and reduced that of
Indian hedgehog protein in murine growth plates,
using both in vivo and in vitro models. They con-
cluded that leptin plays a key role in regulating
chondrocyte proliferation and differentiation in the
growth plate via these mechanisms. Leptin has also
been shown to increase muscle mass in aged mice
().
Systemic Administration of Leptin
The principal studies assessing the effects on bone of
the systemic leptin administration are set out in
Table . Studies have been carried out in leptin-
deficient mice and in normal animals.
Leptin-deficient animals
In  Liu et al. () showed that leptin replacement
in ob/ob mice increased osteoblast number .-fold,
Figure 5. Response of thymidine incorporation in primary
cultures of fetal rat osteoblasts at 24 h to a maximal dose of
leptin, compared with responses to maximal concentrations
of a number of other osteoblast growth factors. Data are
treatment/control ratios and presented as mean 6 SEM. P ,
0.01. *, significantly different from control; EGF, epidermal
growth factor. Reproduced with permission from Cornish J,
Callon KE, Bava U, et al. Leptin directly regulates bone cell
function in vitro and reduces bone fragility in vivo. J Endocrinol
2002; 175 (2):405-415. [© 2018 Illustration Presentation
ENDOCRINE SOCIETY].
https://academic.oup.com/edrv 949
REVIEW
Table 3. Effects of Systemic Leptin Administration on Bone in Animals
Study
Leptin-deficient
Liu et al. 1997 (130)
Steppan et al. 2000 (37)
Hamrick et al. 2005 (39)
Kishida et al. 2005 (40)
Bartell et al. 2011 (84)
Turner et al. 2013 (44)
Philbrick et al. 2017 (35)
Wild-type
Steppan et al. 2000 (37)
Burguera et al. 2001 (125)
Cornish et al. 2002 (109)
Gat-Yablonski et al. 2004 (131)
Hamrick et al. 2005 (39)
950
Model
ob/ob female mice
4-wk-old ob/ob male mice
15-wk-old ob/ob female mice
4-wk-old ob/ob mice
15-wk-old ob/ob female mice
12-wk-old female ob/ob mice
6-wk-old female ob/ob mice
4-wk-old wild-type male mice
Ovariectomized rats
Normal male mice
Prepubertal male mice
15-wk-old female mice
Reid et al Effects of Leptin on the Skeleton
Dosing
Leptin 50 mg/d bid IP for 2 or 4 wk
Leptin 50 mg/d IP for 3 wk
Leptin 2.5 or 10 mg/d SC for 2 wk
Leptin 50 mg/d IP for 2 wk
Leptin 10 mg/d SC for 12 d
Leptin 40 mg/d SC for 3 wk
Leptin infusion (0, 4, 12, 40, 140, or
400 ng/h) for 12 d via SC osmotic
pumps
Leptin 50 mg/d IP for 3 wk
Leptin 100 mg/d SC for 1 mo
Leptin 43 mg/d SC for 4 wk
Leptin 8 mg/g body weight per
day IP
Leptin 2.5 or 10 mg/d SC for 2 wk
Effects
Body weight ↓ 46%, IGF1 ↑ 40%
Tibia: all indices of bone formation ↑↑, no change
in osteoclast numbers
Femur: ↑ length and BMC
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
Total body: ↑ bone area, BMC, and BMD
Fat mass ↓ 43%
Spine: ↓ adipocytes, ↑ osteoclasts
Total body: ↑ BMC and BMD
Femur: ↓ adipocytes
Tibia: ↑ bone formation
↑ Femoral and humeral lengths, ↓ premature
mineralization of growth plates
↓ Weight
↑ Whole body BMD, ↑ muscle mass
Spine: ↑ mineral apposition rate, ↓ marrow
adipocytes
Tibia: ↑ mineral apposition rate, ↓ marrow
adipocytes
↓ Serum insulin; ↑ serum IGF1, OPG, osteocalcin,
pyridinoline, RANKL
↓ Weight
Spine: ↓ TBV, ↑ bone formation
Femur: ↑ bone formation, ↑ linear growth, ↓
osteoclasts
↑ Bone formation and gene expression (bone and
cartilage matrix proteins, bone morphogenetic
protein signaling) in tibia at infusion rates not
changing energy metabolism or hypothalamic
gene expression
No significant effects in femur or total body
Tibia: ↑ TBV and trabecular number, ↓ bone
formation rate
Tibia: ↑ growth plate thickness, ↓ fragility, no
change in bone histomorphometry
↓ Weight gain
Tibia: ↑ length compared with pair-fed controls;
↑ growth plate width, chondrocytes, and
IGF-IR
Total body: No change BMD and BMC
(Continued )
Endocrine Reviews, December 2018, 39(6):938–959

Table 3. Continued
Study Model
Martin et al. 2005 (132) Tail-suspended and control
female rats
Martin et al. 2007 (133) Tail-suspended and control
female rats
Baek et al. 2009 (134) Tail-suspended and control
male rats
Bertoni et al. 2009 (135) Pregnant mice
Stunes et al. 2012 (136) Female rats
Abbreviations: BMC, bone mineral content; CTX, C-telopeptide of type I collagen; OPG, osteoprotegerin; SC, subcutaneous; TBV, trabecular bone volume.
with accompanying substantial increases in bone
formation rates. The nonskeletal phenotype of the ob/
ob mouse is also rapidly reversible with the systemic
administration of leptin. After  weeks leptin ad-
ministration to ob/ob mice, Steppan et al. ()
demonstrated a % decrease in food intake and a %
decrease in total body fat, resulting in a % decrease
in body weight. Liu et al. found a % decrease in body
weight. Some studies have not reported these nutri-
tional changes during leptin treatment, but these ef-
fects are substantial and likely to contribute to the
bone changes that occur, particularly with central
leptin administration where near-starvation can result
from its anorectic effects. Weight loss in normal mice
significantly reduces cortical bone mass (), and
femoral and vertebral bone mass is closely related to
body mass at baseline (r = . to .) and after a
high-fat diet to the increase in body mass in mice
(). The near-normalization of the bone phenotype
over a -week period in the Steppan study (see Table )
in the face of what would usually be regarded as
adverse changes in soft tissue mass strongly suggests an
anabolic effect of leptin on bone ().
Across all the studies of leptin administration in ob/
ob mice, there is a consistent finding of reduced body
weight but increases in appendicular bone formation,
linear bone growth, and bone density after leptin
administration. Although leptin produces substantial
positive effects on bone formation, there is in-
consistency in the effects on osteoclast numbers, which
doi: 10.1210/er.2017-00226
REVIEW
Dosing Effects
Leptin 0.35 mg/kg/d IP for 3–14 d Tibia: ↓ bone loss from tail suspension, ↑ bone
formation, ↓ bone resorption, ↓ OPG in bone,
↓ adipocytes in marrow
Leptin 50 and 500 mg/kg/d IP for High dose ↓ body weight
2 wk
Femur: ↑ BMD with low dose, ↓ BMD with high
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
dose
Tibia: ↑ BMD with low dose, ↓ BMD and bone
formation with high dose; leptin ↓ adipocyte
volume in tibial medulla
↑ CTX, ↓ osteocalcin
Leptin analog (LY35510), 0.35 mg/ Tibia: ↑ BMD, ↑ mineral apposition rate, and ↓
kg/d SC resorbing surface in tail-suspended rats
Leptin 2 mg/kg SC on gestation Longer and wider ossification centers in neonates
days 7, 9, and 11 after leptin
Leptin 100 or 200 mg/d SC for 9 wk ↓ Weight
Femur: no change in BMD; in 100 mg/d group ↓
cortical volume and strength
↓ Whole body BMD in 100 mg/d group
are unchanged or decreased (Table ). In contrast to
the appendicular findings, in the spine, where tra-
becular bone volume is increased in untreated ob/ob
mice, this abnormality was reversed by leptin ad-
ministration, associated with an increase in osteoclast
numbers (, ). Hamrick et al. () showed that the
expansion of adipocyte mass in both the femur and
spine is reversed by leptin treatment.
The study by Philbrick et al. () is particularly
interesting in that it provides details of the dose-
response for the skeletal and nonskeletal effects of
leptin in ob/ob mice. Half-maximal effects on energy
metabolism required leptin dose rates of  to  ng/h,
whereas  to  ng/h produced half-maximal effects
on linear growth and on histomorphometric and
biochemical indices of bone formation (Fig. ).
Changes in histomorphometric indices of osteoblast
activity were seen at the lowest dosage studied ( ng/h),
and longitudinal growth was increased at  ng/h, even
though these infusion rates achieved circulating leptin
concentrations ,% of those in wild-type animals.
Blood glucose, abdominal fat mass, and uterine weight
were unaffected by these infusion rates, although these
parameters were affected at infusion rates of  and
 ng/h, which achieved physiological and supra-
physiological circulating leptin levels, respectively.
Interestingly, the marked suppression of serum
C-telopeptide of type I collagen (CTX, a specific
measure of bone resorption) in the untreated ob/ob
mouse was reversed only by these much higher
https://academic.oup.com/edrv 951
REVIEW

infusion rates, suggesting that leptin effects on bone
resorption are mediated by a different pathway from
that regulating formation.
Wild-type animals
The results of leptin treatment in wild-type animals are
less consistent. Steppan et al. () and Hamrick et al.
() found no changes in bone density with leptin
treatment and no effects on histomorphometry, al-
though skeletal fragility assessed with three-point
higher. This higher dosage reduced fat mass by %
over  weeks, which might explain the negative bone
effects of this pharmacological dosage. Because leptin
reduces body weight, and this itself is likely to affect
bone mass, Gat-Yablonski did studies in which ani-
mals were pair-fed, to disentangle the direct effects of
leptin on the bone from those mediated by weight loss
(). These studies made clear that weight loss
negatively affects linear growth and growth plate
thickness, but that this is reversed by leptin treatment.

Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018

bending of the tibia was diminished in the Cornish
et al. study (). Burguera et al. () found that leptin
reduced postovariectomy bone loss and inhibited the
increase in bone turnover associated with ovariectomy,
similar to the effect of estrogen. Several studies have
found positive effects on the growth plate or on linear
growth, and some reported reduced bone resorption
(, ). Martin et al. () demonstrated beneficial
effects from leptin  mg/kg/d but negative effects on
BMD in the femur and tibia with a dose  times
In summary, the effects of leptin administration were
less dramatic in wild-type animals than in leptin de-
ficiency, but leptin remained anabolic to bone unless
given in very high doses resulting in marked anorexia
and weight loss.
Human studies
The literature describing leptin treatment of humans is
small and is summarized in Table . All studies used
recombinant human methionyl leptin administered

Figure 6. Dose-response comparison of the effects of 12-d subcutaneous leptin infusions on bone formation rate in the distal femur
(upper left panel), Ucp1 gene expression in brown adipose tissue (BAT) (upper right panel), and on bone resorption measured as serum
C-telopeptide of type I collagen (CTX) in ob/ob mice. The bone formation effects are likely to reflect the direct effects of leptin on
osteoblasts, and the actions on Ucp1 reflect leptin’s effects on energy metabolism, probably mediated through the CNS. Unlike the
various measures of bone formation assessed, serum CTX (lower panel) was normalized only at high leptin infusion rates, suggesting an
indirect mechanism for this action. The x-axes show leptin infusion rates throughout the 12-d experimental period. The greater
sensitivity to leptin of bone compared with energy metabolism was reflected in activation of Jak/Stat signaling in the tibia at much
lower leptin infusion rates than were needed for activation of Jak/Stat signaling in the hypothalamus (data not shown). Data are
mean 6 SEM. “a” indicates different from vehicle-treated ob/ob mice (ob/ob 0), P , 0.05. Wild-type (WT) mice are shown as
a reference group. Reproduced with permission from Philbrick KA, Wong CP, Branscum AJ, et al. Leptin stimulates bone formation in
ob/ob mice at doses having minimal impact on energy metabolism. J Endocrinol 2017; 232 (3):461-474. [© 2018 Illustration
Presentation ENDOCRINE SOCIETY].

952 Reid et al Effects of Leptin on the Skeleton Endocrine Reviews, December 2018, 39(6):938–959

Table 4. Effects of Leptin Administration on Bone in Humans
Study Patients
Farooqi et al. 1999 (54) 9-y-old girl with
congenital leptin
deficiency
Simha et al. 2002 (51) 2 women with
generalized
lipodystrophy
Moran et al. 2004 (139) 3 men and 11 women
with generalized (12)
or partial
lipodystrophy
Welt et al. 2004 (140) 8 women with
hypothalamic
amenorrhea
Chou et al. 2011 (141) 20 women with
hypothalamic
amenorrhea
randomly assigned, 7
on leptin completed
Conroy et al. 2011 (142) 8 women, 4 men (2
nonobese, 10 obese)
being maintained at
baseline weight
210%
Sienkiewicz 2011 (143) 6 women with
hypothalamic
amenorrhea from
Chou study
Foo et al. 2014 (144) 18 women with
hypothalamic
amenorrhea
randomly assigned,
10 to leptin
Met-leptin was given subcutaneously in all studies.
Abbreviations: BMC, bone mineral content; BSAP, bone-specific alkaline phosphatase; NTX, N-telopeptide of type I collagen; OPG, osteoprotegerin; PINP, procollagen type 1 N-terminal
propeptide.
subcutaneously once or twice a day. The Farooqi study
et al. () is a case report of a person with congenital
leptin deficiency who had a % decrease in food
intake accompanied by profound weight loss during a
year of leptin treatment. These nutritional changes
were associated with a moderate increase in total body
bone mineral content. In contrast, the cases of lipo-
dystrophy or hypothalamic amenorrhea had low body
weights at baseline, but showed further loss of fat
mass and body weight during leptin treatment. Those
studies either showed no change in bone density (,
doi: 10.1210/er.2017-00226
REVIEW
Regimen Bone Effects Other Effects
Met-leptin 0.028 mg/kg Total body BMC ↑ 0.15 Weight 94.4 kg → 78.0
of lean mass per day kg kg; food intake ↓ 40%
for 12 mo
Met-leptin 0.02–0.08 No change in BMD Weight ↓ 2–3 kg
mg/kg/d for 16–18 (spine, hip, total body,
mo radius); no change in
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
bone turnover
markers or PTH
Met-leptin 0.01–0.06 No change in BMD Weight ↓ 3.3 kg
mg/kg/d for 12 mo (total body); no
change in bone
turnover markers
Met-leptin 0.08 mg/kg/ ↑ Bone alkaline Weight ↓ 2.5 kg; ↑ LH,
d for 3 mo phosphatase and estradiol, thyroid
osteocalcin hormones, IGF1, IGF-
binding protein-3
Met-leptin 0.08 mg/kg/ ↑ Osteocalcin and Fat mass ↓ 2 kg despite
d for 36 wk with transient ↑ urine NTX leptin dosage
dosage adjustment reductions; return of
menstruation in 70%
and normalization of
gonadal, thyroid,
growth hormone,
and adrenal axes
Met-leptin 0.08 mg/kg No change in PINP, Weight stable at 10%
fat mass per day in BSAP, NTX, or PTH below baseline
men and 0.14 mg/kg
fat mass per day in
women, with dosage
adjustment
Met-leptin 0.04–0.012 ↑ Spine BMD, ↓ CTX Weight ↓ 3%; ↑ IGF1
mg/kg/d for another
6–12 mo
Met-leptin 0.08 mg/kg/ ↓ PTH at 36 wk and in Weight changes not
d for 36 wk with RANKL/OPG ratio reported
dosage adjustment
) or a small increase (). Bone turnover markers
were either unchanged (, , ) or increased (,
), apart from a reduction in the bone resorption
marker CTX in the Sienkiewicz studies ().
Whereas Simha and Conroy both reported no
change in parathyroid hormone concentrations, Foo
found that PTH levels were reduced by %, although
this change became apparent only between  and
 weeks of leptin treatment (). The magnitude and
time-course of the weight change in this study is not
reported, so it is not possible to determine any
https://academic.oup.com/edrv 953
REVIEW
temporal relationship between weight loss and PTH
levels. The Foo study also showed a reduction in the
ratio of RANKL to osteoprotegerin, suggesting an
antiresorptive effect of leptin, possibly secondary to
inhibition of PTH release. However the inconsistency
of the changes in PTH levels and bone turnover
markers in the other human studies means that
changes in PTH cannot be regarded as an established
mechanism of the leptin effects on bone.
Two studies in women with hypothalamic
amenorrhea showed profound changes in sex hor-
mone levels, thyroid hormones and the IGF system.
In the study of Chou et al. (), % of the
amenorrheic women treated with leptin had a return
of menstruation. In the Welt et al. () study, es-
tradiol levels increased threefold after  months of
leptin treatment, thyroid hormone levels by % to
%, and IGF by %. All these changes would be
expected to have beneficial effects on bone formation
and bone mass.
Despite some inconsistencies between these
studies, their results are entirely consistent with the
body of animal data and indicate that the systemic
administration of leptin to either obese or un-
derweight subjects results in weight loss, with either
preservation of bone density or increased bone
mass. In almost all other contexts, weight loss is
associated with reduction in bone mass. Therefore,
these studies reinforce the body of evidence in-
dicating that systemic administration of leptin is
anabolic to bone. These studies do not resolve
whether this is a direct or indirect effect. The
changes in sex hormones, thyroid hormones, and
the IGF system demonstrated by Welt et al. ()
and Chou et al. () indicate a high likelihood that,
in humans, some of leptin’s effects on bone are
indirectly mediated through these hormones.
Integrating the Direct and Indirect Effects of
Leptin on the Skeleton
The literature reviewed above indicates that leptin has
direct anabolic effects on bone cells or can influence
bone indirectly in a number of ways: via its actions in
the CNS, which are catabolic to vertebral trabecular
bone; via changes in weight (catabolic); and via effects
on the production of other hormones, which are
usually anabolic. Leptin’s role in bone physiology will
be determined by the interaction and balance of these
conflicting effects. It is possible that this balance
might vary between species; the SNS-mediated effects
are well established in mice but not in humans,
where adrenergic blockers have little effect on the
skeleton. The balance of leptin’s anabolic and cat-
abolic effects might also vary according to factors
such as body weight, baseline circulating leptin
levels, the level of leptin resistance, and the presence
954 Reid et al Effects of Leptin on the Skeleton
of specific pathologies. Therefore, circumspection is
needed in defining leptin’s role in any particular
context.
There are limitations in the experimental models
used to demonstrate the direct and indirect effects of
leptin on bone. Leptin in the circulation crosses the
blood-brain barrier, so it can affect hypothalamic
and pituitary function. The latter is likely to be
particularly relevant to the effects of systemic leptin
administration on women with hypothalamic
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
amenorrhea, in whom changes in gonadal, thyroid,
and adrenal function and in circulating levels of
growth hormone and IGF were observed after
systemic treatment (Table ). However, the reverse
is also the case, because there is reabsorption of the
cerebrospinal fluid into the blood (). Maness
et al. () showed that the amount of leptin in the
peripheral circulation after injection into the ce-
rebral ventricles is comparable to levels seen
 minutes after intravenous administration. Thus,
central leptin infusion at  ng/h (i.e., similar to or
less than dosages used in central leptin adminis-
tration studies) produces detectable levels of leptin
in the circulation and results in leptin receptor
activation in peripheral cells such as thymocytes
(). Therefore, some of the short-term effects of
centrally administered leptin might be mediated by
direct peripheral effects. Furthermore, rats with
sustained central leptin expression produced by a
single ICV injection of a recombinant adenoasso-
ciated virus vector encoding leptin have marked
peripheral hypoleptinemia and hypoinsulinemia
(). Weight loss alone can reduce circulating
leptin by % (), but pair-feeding studies indicate
that central administration of leptin reduces its
circulating levels independent of the weight loss
(). The hypoinsulinemia that follows central
leptin administration is likely to be accompanied by
reductions in amylin and preptin, which are also
secreted by the pancreatic b cell. All these peptides
have anabolic effects on bone (–). Thus, the
direct anabolic effects on bone of this cluster of
peptides and of leptin itself are substantially reduced
by central leptin administration. A diagram sum-
marizing these possible pathways for leptin effects on
bone is shown in Fig. .
When assessing studies of centrally and periph-
erally administered leptin, we need to consider how
physiological the dosages used are. Philbrick et al. ()
demonstrated that a systemic infusion rate of  ng/h
(equivalent to . mg/d) achieves physiological cir-
culating leptin levels. By this standard, many of the
studies of systemic administration set out in Table 
used substantially supraphysiological leptin dosages.
However, Maness et al. () showed that the brain/
serum ratios of leptin produced by ICV injection are
 times higher than those produced by intravenous
administration, so even delivery of leptin into the
Endocrine Reviews, December 2018, 39(6):938–959

Adipose tissue
Marrow
adipocytes
Leptin in
circulation
– Blood leptin
– Pituitary
Leptin
in bone
LepRb
Osteoblast Chondrocyte
Proliferation, differentiation, Proliferation, differentiation,
protein synthesis, mineralization, growth plate thickness
OPG; RANKL
cerebral ventricles at  ng/h might produce brain levels
much higher than would occur physiologically.
Several lines of evidence suggest that the direct
effects of leptin on bone are likely to be dominant in
most circumstances. Leptin is produced outside the
CNS and is present in the circulation in concen-
trations  to  times higher than those in the
cerebrospinal fluid. It is produced in bone marrow
adipocytes, chondrocytes (), and cells of the
osteoblast lineage (), so its concentrations
around bone cells might be even higher than in the
circulation. The elegant dose-response leptin in-
fusion studies that Philbrick et al. () carried out in
ob/ob mice provide persuasive evidence that leptin
directly stimulates bone cells, increasing bone
formation and producing robust changes in Jak/
Stat signaling genes in bone and bone cell–related
genes at leptin infusion rates that do not activate
Jak/Stat signaling in the hypothalamus or produce
its centrally mediated effects on energy meta-
bolism. This evidence is supported by the finding
that transferring db/db bone marrow into wild-type
mice reproduces the skeletal phenotype of the db/
db mouse without evidence of any change in the
CNS actions of leptin (), indicating that the loss
of leptin signaling in bone alone is adequate to
reproduce the bone effects of leptin deficiency.
However, Shi et al. () found contrary results, that
selective knockout of osteoblastic leptin receptors
did not affect the bone phenotype in mice. Also, the
Philbrick et al. () work has only just appeared,
and other groups have not yet had the opportunity
doi: 10.1210/er.2017-00226
REVIEW
Figure 7. Pathways by
which leptin, originating in
adipose tissue, bone
Hypothalamus marrow adipocytes, and
osteoblasts, influences
bone. The width of the
yellow arrows indicates the
Sympathetic leptin concentrations
nervous found in bone and in the
system
CNS. [© 2018 Illustration
Presentation ENDOCRINE
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
Weight loss
SOCIETY].
Blood insulin
Euglycemia
Eugonadism
+ Euthyroidism
Eucortisolism
IGF1
© 2018 Illustration Presentation ENDOCRINE SOCIETY
to reproduce these findings. Thus, the balance of
the central and peripheral effects of leptin on bone
remains an area of substantial controversy, reso-
lution of which will require additional experi-
mental work.
Whether the balance of central and peripheral
effects of leptin is similar in different models,
particularly in humans, is unknown. In fact, the
largest deficit in our knowledge of the effects of
leptin on the skeleton is in human studies, and
there is a need for substantial work in this regard. A
careful study of the dose response of leptin
treatment in patients who are leptin-deficient al-
ready receiving sex hormone replacement could
address leptin’s effects on the skeleton in humans,
but the rarity of such patients is a real challenge for
such studies. The fact that leptin and body weight
are positively related to bone density and inversely
related to fracture risk suggests that the direct
peripheral effects predominate in humans, and this
supposition is supported by the absence of evi-
dence that b-blockers significantly affect human
bone health. The absence of a clear bone pheno-
type in the small number of human cases of severe
long-term leptin deficiency that have been de-
scribed suggests that neither peripheral nor cen-
tral effects are critical to human bone health.
However, the demonstration of a neural pathway
involving the SNS that permits the CNS to in-
fluence bone formation is a fascinating develop-
ment in this area of research. It remains possible
that in some contexts this pathway might be
https://academic.oup.com/edrv 955
REVIEW
physiologically or pathologically important in
human health. Recognition of the interactions
between leptin and bone has broadened our
References
1. Reid IR. Fat and bone. Arch Biochem Biophys. 2010;
503(1):20–27.
2. Johansson H, Kanis JA, Odén A, McCloskey E,
Chapurlat RD, Christiansen C, Cummings SR, Diez-
Perez A, Eisman JA, Fujiwara S, Glüer CC, Goltzman
D, Hans D, Khaw KT, Krieg MA, Kröger H, LaCroix
AZ, Lau E, Leslie WD, Mellström D, Melton LJ III,
O’Neill TW, Pasco JA, Prior JC, Reid DM, Rivadeneira
F, van Staa T, Yoshimura N, Zillikens MC. A meta-
analysis of the association of fracture risk and body
mass index in women. J Bone Miner Res. 2014;29(1):
223–233.
3. Reid IR. Relationships between fat and bone.
Osteoporos Int. 2008;19(5):595–606.
4. De Laet C, Kanis JA, Odén A, Johanson H, Johnell O,
Delmas P, Eisman JA, Kroger H, Fujiwara S, Garnero
P, McCloskey EV, Mellstrom D, Melton LJ III,
Meunier PJ, Pols HAP, Reeve J, Silman A,
Tenenhouse A. Body mass index as a predictor of
fracture risk: a meta-analysis. Osteoporos Int. 2005;
16(11):1330–1338.
5. Ensrud KE, Lipschutz RC, Cauley JA, Seeley D, Nevitt
MC, Scott J, Orwoll ES, Genant HK, Cummings SR;
Study of Osteoporotic Fractures Research Group.
Body size and hip fracture risk in older women:
a prospective study. Am J Med. 1997;103(4):274–280.
6. Schott AM, Cormier C, Hans D, Favier F, Hausherr E,
Dargent-Molina P, Delmas PD, Ribot C, Sebert JL,
Breart G, Meunier PJ. How hip and whole-body
bone mineral density predict hip fracture in elderly
women: the EPIDOS Prospective Study. Osteoporos
Int. 1998;8(3):247–254.
7. Lau EMC, Chan YH, Chan M, Woo J, Griffith J, Chan
HHL, Leung PC. Vertebral deformity in Chinese
men: prevalence, risk factors, bone mineral density,
and body composition measurements. Calcif Tissue
Int. 2000;66(1):47–52.
8. Lacombe J, Cairns BJ, Green J, Reeves GK, Beral V,
Armstrong MEG; Million Women Study collabo-
rators. The effects of age, adiposity, and physical
activity on the risk of seven site-specific fractures in
postmenopausal women. J Bone Miner Res. 2016;
31(8):1559–1568.
9. Compston JE, Flahive J, Hosmer DW, Watts NB, Siris
ES, Silverman S, Saag KG, Roux C, Rossini M,
Pfeilschifter J, Nieves JW, Netelenbos JC, March L,
LaCroix AZ, Hooven FH, Greenspan SL, Gehlbach
SH, Dı́ez-Pérez A, Cooper C, Chapurlat RD, Boonen
S, Anderson FA Jr, Adami S, Adachi JD; GLOW
Investigators. Relationship of weight, height, and
body mass index with fracture risk at different sites
in postmenopausal women: the Global Longitudi-
nal Study of Osteoporosis in Women (GLOW).
J Bone Miner Res. 2014;29(2):487–493.
10. Zhang Y, Proenca R, Maffei M, Barone M, Leopold L,
Friedman JM. Positional cloning of the mouse obese
gene and its human homologue. Nature. 1994;
372(6505):425–432.
11. Laharrague P, Larrouy D, Fontanilles AM, Truel N,
Campfield A, Tenenbaum R, Galitzky J, Corberand
JX, Pénicaud L, Casteilla L. High expression of leptin
by human bone marrow adipocytes in primary
culture. FASEB J. 1998;12(9):747–752.
956 Reid et al Effects of Leptin on the Skeleton
appreciation of the regulatory interactions oc-
curring in the skeleton, particularly the interplay
between energy and bone homeostasis.
12. Bassilana F, Susa M, Keller HJ, Halleux C. Human
mesenchymal stem cells undergoing osteo-
genic differentiation express leptin and func-
tional leptin receptor. J Bone Miner Res. 2000;
15(suppl 1):S378.
13. Reseland JE, Syversen U, Bakke I, Qvigstad G, Eide
LG, Hjertner O, Gordeladze JO, Drevon CA. Leptin
is expressed in and secreted from primary cultures
of human osteoblasts and promotes bone min-
eralization. J Bone Miner Res. 2001;16(8):
1426–1433.
14. Kume K, Satomura K, Nishisho S, Kitaoka E,
Yamanouchi K, Tobiume S, Nagayama M. Potential
role of leptin in endochondral ossification. J Histochem
Cytochem. 2002;50(2):159–169.
15. Park H-K, Ahima RS. Physiology of leptin: energy
homeostasis, neuroendocrine function and meta-
bolism. Metabolism. 2015;64(1):24–34.
16. Licinio J, Negrão AB, Mantzoros C, Kaklamani V,
Wong ML, Bongiorno PB, Negro PP, Mulla A,
Veldhuis JD, Cearnal L, Flier JS, Gold PW. Sex dif-
ferences in circulating human leptin pulse ampli-
tude: clinical implications. J Clin Endocrinol Metab.
1998;83(11):4140–4147.
17. Chan JL, Heist K, DePaoli AM, Veldhuis JD,
Mantzoros CS. The role of falling leptin levels in the
neuroendocrine and metabolic adaptation to short-
term starvation in healthy men. J Clin Invest. 2003;
111(9):1409–1421.
18. Rosenbaum M, Leibel RL. Clinical review 107: role of
gonadal steroids in the sexual dimorphisms in body
composition and circulating concentrations of
leptin. J Clin Endocrinol Metab. 1999;84:1784–1789.
19. Ahima RS, Osei SY. Leptin signaling. Physiol Behav.
2004;81(2):223–241.
20. Flak JN, Myers MG Jr. Minireview: CNS mechanisms
of leptin action. Mol Endocrinol. 2016;30(1):3–12.
21. Tartaglia LA. The leptin receptor. J Biol Chem. 1997;
272(10):6093–6096.
22. de Luca C, Kowalski TJ, Zhang Y, Elmquist JK, Lee C,
Kilimann MW, Ludwig T, Liu S-M, Chua SC Jr.
Complete rescue of obesity, diabetes, and infertility
in db/db mice by neuron-specific LEPR-B transgenes.
J Clin Invest. 2005;115(12):3484–3493.
23. Bjørbaek C, Elmquist JK, Michl P, Ahima RS, van
Bueren A, McCall AL, Flier JS. Expression of leptin
receptor isoforms in rat brain microvessels. Endo-
crinology. 1998;139(8):3485–3491.
24. Dalamaga M, Chou SH, Shields K, Papageorgiou P,
Polyzos SA, Mantzoros CS. Leptin at the intersection
of neuroendocrinology and metabolism: current
evidence and therapeutic perspectives. Cell Metab.
2013;18(1):29–42.
25. Haynes WG, Morgan DA, Walsh SA, Mark AL, Sivitz
WI. Receptor-mediated regional sympathetic nerve
activation by leptin. J Clin Invest. 1997;100(2):270–278.
26. Scarpace PJ, Matheny M, Pollock BH, Tümer N.
Leptin increases uncoupling protein expression and
energy expenditure. Am J Physiol. 1997;273(1 Pt 1):
E226–E230.
27. Mantzoros CS, Flier JS. Editorial: leptin as a thera-
peutic agent--trials and tribulations. J Clin Endocrinol
Metab. 2000;85(11):4000–4002.
28. Myers MG Jr, Heymsfield SB, Haft C, Kahn BB,
Laughlin M, Leibel RL, Tschöp MH, Yanovski JA.
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
Challenges and opportunities of defining clinical
leptin resistance. Cell Metab. 2012;15(2):150–156.
29. Jung CH, Kim M-S. Molecular mechanisms of
central leptin resistance in obesity. Arch Pharm Res.
2013;36(2):201–207.
30. Rizwan MZ, Mehlitz S, Grattan DR, Tups A. Tem-
poral and regional onset of leptin resistance in diet-
induced obese mice. J Neuroendocrinol. 2017;29(10):
e12481.
31. El-Haschimi K, Pierroz DD, Hileman SM, Bjørbaek C,
Flier JS. Two defects contribute to hypothalamic
leptin resistance in mice with diet-induced obesity.
J Clin Invest. 2000;105(12):1827–1832.
32. Banks WA, Kastin AJ, Huang W, Jaspan JB, Maness
LM. Leptin enters the brain by a saturable sys-
tem independent of insulin. Peptides. 1996;17(2):
305–311.
33. Caro JF, Kolaczynski JW, Nyce MR, Ohannesian JP,
Opentanova I, Goldman WH, Lynn RB, Zhang PL,
Sinha MK, Considine RV. Decreased cerebrospinal-
fluid/serum leptin ratio in obesity: a possible
mechanism for leptin resistance. Lancet. 1996;
348(9021):159–161.
34. Nam SY, Kratzsch J, Kim KW, Kim KR, Lim SK,
Marcus C. Cerebrospinal fluid and plasma con-
centrations of leptin, NPY, and alpha-MSH in obese
women and their relationship to negative energy
balance. J Clin Endocrinol Metab. 2001;86(10):
4849–4853.
35. Philbrick KA, Wong CP, Branscum AJ, Turner RT,
Iwaniec UT. Leptin stimulates bone formation in
ob/ob mice at doses having minimal impact on
energy metabolism. J Endocrinol. 2017;232(3):
461–474.
36. Ducy P, Amling M, Takeda S, Priemel M, Schilling AF,
Beil FT, Shen J, Vinson C, Rueger JM, Karsenty G.
Leptin inhibits bone formation through a hypo-
thalamic relay: a central control of bone mass. Cell.
2000;100(2):197–207.
37. Steppan CM, Crawford DT, Chidsey-Frink KL, Ke H,
Swick AG. Leptin is a potent stimulator of bone
growth in ob/ob mice. Regul Pept. 2000;92(1–3):73–78.
38. Hamrick MW, Pennington C, Newton D, Xie D,
Isales C. Leptin deficiency produces contrasting
phenotypes in bones of the limb and spine. Bone.
2004;34(3):376–383.
39. Hamrick MW, Della-Fera MA, Choi YH, Pennington
C, Hartzell D, Baile CA. Leptin treatment induces
loss of bone marrow adipocytes and increases bone
formation in leptin-deficient ob/ob mice. J Bone
Miner Res. 2005;20(6):994–1001.
40. Kishida Y, Hirao M, Tamai N, Nampei A, Fujimoto T,
Nakase T, Shimizu N, Yoshikawa H, Myoui A. Leptin
regulates chondrocyte differentiation and matrix
maturation during endochondral ossification. Bone.
2005;37(5):607–621.
41. Baldock PA, Sainsbury A, Allison S, Lin EJD, Couzens
M, Boey D, Enriquez R, During M, Herzog H,
Gardiner EM. Hypothalamic control of bone for-
mation: distinct actions of leptin and y2 receptor
pathways. J Bone Miner Res. 2005;20(10):1851–1857.
Endocrine Reviews, December 2018, 39(6):938–959

42. Ealey KN, Fonseca D, Archer MC, Ward WE. Bone
abnormalities in adolescent leptin-deficient mice.
Regul Pept. 2006;136(1–3):9–13.
43. Iwaniec UT, Boghossian S, Lapke PD, Turner RT,
Kalra SP. Central leptin gene therapy corrects
skeletal abnormalities in leptin-deficient ob/ob
mice. Peptides. 2007;28(5):1012–1019.
44. Turner RT, Kalra SP, Wong CP, Philbrick KA,
Lindenmaier LB, Boghossian S, Iwaniec UT. Pe-
ripheral leptin regulates bone formation. J Bone
Miner Res. 2013;28(1):22–34.
45. Lorentzon R, Alehagen U, Boquist L. Osteopenia in
mice with genetic diabetes. Diabetes Res Clin Pract.
1986;2(3):157–163.
46. Takeshita N, Mutoh S, Yamaguchi I; Basic Research
Group. Osteopenia in genetically diabetic DB/DB
mice and effects of 1a-hydroxyvitamin D3 on the
osteopenia. Life Sci. 1995;56(13):1095–1101.
47. Williams GA, Callon KE, Watson M, Costa JL, Ding Y,
Dickinson M, Wang Y, Naot D, Reid IR, Cornish J.
Skeletal phenotype of the leptin receptor-deficient
db/db mouse. J Bone Miner Res. 2011;26(8):
1698–1709.
48. Foldes J, Shih MS, Levy J. Bone structure and calcium
metabolism in obese Zucker rats. Int J Obes Relat
Metab Disord. 1992;16(2):95–102.
49. Mathey J, Horcajada-Molteni MN, Chanteranne B,
Picherit C, Puel C, Lebecque P, Cubizoles C, Davicco
MJ, Coxam V, Barlet JP. Bone mass in obese diabetic
Zucker rats: influence of treadmill running. Calcif
Tissue Int. 2002;70(4):305–311.
50. Tamasi JA, Arey BJ, Bertolini DR, Feyen JHM.
Characterization of bone structure in leptin
receptor–deficient Zucker (fa/fa) rats. J Bone Miner
Res. 2003;18(9):1605–1611.
51. Simha V, Zerwekh JE, Sakhaee K, Garg A. Effect of
subcutaneous leptin replacement therapy on bone
metabolism in patients with generalized lipodys-
trophy. J Clin Endocrinol Metab. 2002;87(11):
4942–4945.
52. Ozata M. Different presentation of bone mass in
mice and humans with congenital leptin deficiency.
J Clin Endocrinol Metab. 2002;87(2):951.
53. Himms-Hagen J. Physiological roles of the leptin
endocrine system: differences between mice and
humans. Crit Rev Clin Lab Sci. 1999;36(6):575–655.
54. Farooqi IS, Jebb SA, Langmack G, Lawrence E,
Cheetham CH, Prentice AM, Hughes IA, McCamish
MA, O’Rahilly S. Effects of recombinant leptin
therapy in a child with congenital leptin deficiency.
N Engl J Med. 1999;341(12):879–884.
55. Weiss LA, Barrett-Connor E, von Mühlen D, Clark P.
Leptin predicts BMD and bone resorption in older
women but not older men: the Rancho Bernardo
study. J Bone Miner Res. 2006;21(5):758–764.
56. Reid IR, Richards JB. Adipokine effects on bone. Clin
Rev Bone Miner Metab. 2009;7(3):240–248.
57. Goulding A, Taylor RW. Plasma leptin values in
relation to bone mass and density and to dynamic
biochemical markers of bone resorption and for-
mation in postmenopausal women. Calcif Tissue Int.
1998;63(6):456–458.
58. Mpalaris V, Anagnostis P, Anastasilakis AD, Goulis
DG, Doumas A, Iakovou I. Serum leptin, adiponectin
and ghrelin concentrations in post-menopausal
women: is there an association with bone mineral
density? Maturitas. 2016;88:32–36.
59. Ruhl CE, Everhart JE. Relationship of serum leptin
concentration with bone mineral density in the
United States population. J Bone Miner Res. 2002;
17(10):1896–1903.
60. Sato M, Takeda N, Sarui H, Takami R, Takami K,
Hayashi M, Sasaki A, Kawachi S, Yoshino K,
Yasuda K. Association between serum leptin
doi: 10.1210/er.2017-00226
concentrations and bone mineral density, and
biochemical markers of bone turnover in adult
men. J Clin Endocrinol Metab. 2001;86(11):
5273–5276.
61. Ho-Pham LT, Lai TQ, Nguyen UDT, Bui QV, Nguyen
TV. Delineating the relationship between leptin, fat
mass, and bone mineral density: a mediation
analysis. Calcif Tissue Int. 2017;100(1):13–19.
62. Javaid MK, Godfrey KM, Taylor P, Robinson SM,
Crozier SR, Dennison EM, Robinson JS, Breier BR,
Arden NK, Cooper C. Umbilical cord leptin predicts
neonatal bone mass. Calcif Tissue Int. 2005;76(5):
341–347.
63. Rhie YJ, Lee KH, Chung SC, Kim HS, Kim DH. Effects
of body composition, leptin, and adiponectin on
bone mineral density in prepubertal girls. J Korean
Med Sci. 2010;25(8):1187–1190.
64. Huang KC, Cheng WC, Yen RF, Tsai KS, Tai TY, Yang
WS. Lack of independent relationship between
plasma adiponectin, leptin levels and bone density
in nondiabetic female adolescents. Clin Endocrinol
(Oxf). 2004;61(2):204–208.
65. Yamauchi M, Sugimoto T, Yamaguchi T, Nakaoka
D, Kanzawa M, Yano S, Ozuru R, Sugishita T,
Chihara K. Plasma leptin concentrations are
associated with bone mineral density and
the presence of vertebral fractures in post-
menopausal women. Clin Endocrinol (Oxf). 2001;
55(3):341–347.
66. Schett G, Kiechl S, Bonora E, Redlich K, Woloszczuk
W, Oberhollenzer F, Jocher J, Dorizzi R, Muggeo M,
Smolen J, Willeit J. Serum leptin level and the risk of
nontraumatic fracture. Am J Med. 2004;117(12):
952–956.
67. Barbour KE, Zmuda JM, Boudreau R, Strotmeyer ES,
Horwitz MJ, Evans RW, Kanaya AM, Harris TB, Bauer
DC, Cauley JA. Adipokines and the risk of fracture
in older adults. J Bone Miner Res. 2011;26(7):
1568–1576.
68. Shaarawy M, Abassi AF, Hassan H, Salem ME. Re-
lationship between serum leptin concentrations
and bone mineral density as well as biochemical
markers of bone turnover in women with post-
menopausal osteoporosis. Fertil Steril. 2003;79(4):
919–924.
69. Blain H, Vuillemin A, Guillemin F, Durant R, Hanesse
B, de Talance N, Doucet B, Jeandel C. Serum leptin
level is a predictor of bone mineral density in
postmenopausal women. J Clin Endocrinol Metab.
2002;87(3):1030–1035.
70. Scariano JK, Garry PJ, Montoya GD, Chandani AK,
Wilson JM, Baumgartner RN. Serum leptin levels,
bone mineral density and osteoblast alkaline
phosphatase activity in elderly men and women.
Mech Ageing Dev. 2003;124(3):281–286.
71. Prouteau S, Benhamou L, Courteix D. Relationships
between serum leptin and bone markers during
stable weight, weight reduction and weight regain
in male and female judoists. Eur J Endocrinol. 2006;
154(3):389–395.
72. Grethen E, Hill KM, Jones R, Cacucci BM, Gupta CE,
Acton A, Considine RV, Peacock M. Serum leptin,
parathyroid hormone, 1,25-dihydroxyvitamin D,
fibroblast growth factor 23, bone alkaline phos-
phatase, and sclerostin relationships in obesity. J Clin
Endocrinol Metab. 2012;97(5):1655–1662.
73. Billington EO, Gamble GD, Reid IR. Parathyroid
hormone reflects adiposity and cardiometabolic
indices but not bone density in normal men.
Bonekey Rep. 2016;5:852.
74. Bhadada SK, Bhansali A, Shah VN, Rao DS. Changes
in serum leptin and adiponectin concentra-
tions and insulin resistance after curative para-
thyroidectomy in moderate to severe primary
https://academic.oup.com/edrv
REVIEW
hyperparathyroidism. Singapore Med J. 2011;
52(12):890–893.
75. Grey AB, Evans MC, Stapleton JP, Reid IR. Body
weight and bone mineral density in post-
menopausal women with primary hyperpara-
thyroidism. Ann Intern Med. 1994;121(10):
745–749.
76. Hoang D, Broer N, Roman SA, Yao X, Abitbol N, Li F,
Sosa JA, Sue GR, DeWan AT, Wong ML, Licinio J,
Simpson C, Li AY, Pizzoferrato N, Narayan D. Leptin
signaling and hyperparathyroidism: clinical and
genetic associations. J Am Coll Surg. 2014;218(6):
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
1239–1250.e4.
77. Matsunuma A, Kawane T, Maeda T, Hamada S,
Horiuchi N. Leptin corrects increased gene
expression of renal 25-hydroxyvitamin D3-1 alpha-
hydroxylase and -24-hydroxylase in leptin-
deficient, ob/ob mice. Endocrinology. 2004;
145(3):1367–1375.
78. Tsuji K, Maeda T, Kawane T, Matsunuma A,
Horiuchi N. Leptin stimulates fibroblast growth
factor 23 expression in bone and suppresses renal
1alpha,25-dihydroxyvitamin D3 synthesis in leptin-
deficient mice. J Bone Miner Res. 2010;25(8):
1711–1723.
79. Hoang D, Broer N, Sosa JA, Abitbol N, Yao X, Li F,
Rivera-Molina F, Toomre DK, Roman SA, Sue G, Kim
S, Li AY, Callender GG, Simpson C, Narayan D.
Leptin is produced by parathyroid glands and
stimulates parathyroid hormone secretion. Ann
Surg. 2017;266(6):1075–1083.
80. Mirza MA, Alsiö J, Hammarstedt A, Erben RG,
Michaëlsson K, Tivesten A, Marsell R, Orwoll E,
Karlsson MK, Ljunggren O, Mellström D, Lind L,
Ohlsson C, Larsson TE. Circulating fibroblast growth
factor-23 is associated with fat mass and dyslipi-
demia in two independent cohorts of elderly in-
dividuals. Arterioscler Thromb Vasc Biol. 2011;31(1):
219–227.
81. Billington EO, Gamble GD, Bristow S, Reid IR. Serum
phosphate is related to adiposity in healthy adults:
cross-sectional assessment of three independent
cohorts. Eur J Clin Invest. 2017;47(7):486–493.
82. Saini RK, Kaneko I, Jurutka PW, Forster R, Hsieh A,
Hsieh J-C, Haussler MR, Whitfield GK. 1,25-
dihydroxyvitamin D(3) regulation of fibroblast
growth factor-23 expression in bone cells: evidence
for primary and secondary mechanisms modulated
by leptin and interleukin-6. Calcif Tissue Int. 2013;
92(4):339–353.
83. Matsunuma A, Horiuchi N. Leptin attenuates gene
expression for renal 25-hydroxyvitamin D3-1alpha-
hydroxylase in mice via the long form of the leptin
receptor. Arch Biochem Biophys. 2007;463(1):
118–127.
84. Bartell SM, Rayalam S, Ambati S, Gaddam DR,
Hartzell DL, Hamrick M, She JX, Della-Fera MA, Baile
CA. Central (ICV) leptin injection increases bone
formation, bone mineral density, muscle mass, se-
rum IGF-1, and the expression of osteogenic genes
in leptin-deficient ob/ob mice. J Bone Miner Res.
2011;26(8):1710–1720.
85. Pogoda P, Egermann M, Schnell JC, Priemel M,
Schilling AF, Alini M, Schinke T, Rueger JM,
Schneider E, Clarke I, Amling M. Leptin in-
hibits bone formation not only in rodents, but
also in sheep. J Bone Miner Res. 2006;21(10):
1591–1599.
86. Takeda S, Elefteriou F, Levasseur R, Liu X, Zhao L,
Parker KL, Armstrong D, Ducy P, Karsenty G. Leptin
regulates bone formation via the sympathetic
nervous system. Cell. 2002;111(3):305–317.
87. Ruffin M, Nicolaidis S. Electrical stimulation of the
ventromedial hypothalamus enhances both fat
957
REVIEW
utilization and metabolic rate that precede and
parallel the inhibition of feeding behavior. Brain Res.
1999;846(1):23–29.
88. Elefteriou F, Ahn JD, Takeda S, Starbuck M, Yang X,
Liu X, Kondo H, Richards WG, Bannon TW, Noda
M, Clement K, Vaisse C, Karsenty G. Leptin regu-
lation of bone resorption by the sympathetic
nervous system and CART. Nature. 2005;434(7032):
514–520.
89. Pierroz DD, Bonnet N, Bianchi EN, Bouxsein ML,
Baldock PA, Rizzoli R, Ferrari SL. Deletion of
b-adrenergic receptor 1, 2, or both leads to dif-
ferent bone phenotypes and response to me-
chanical stimulation. J Bone Miner Res. 2012;27(6):
1252–1262.
90. Shi Y, Yadav VK, Suda N, Liu XS, Guo XE, Myers MG
Jr, Karsenty G. Dissociation of the neuronal regu-
lation of bone mass and energy metabolism by
leptin in vivo. Proc Natl Acad Sci USA. 2008;105(51):
20529–20533.
91. Gallardo N, Bonzón-Kulichenko E, Fernández-
Agulló T, Moltó E, Gómez-Alonso S, Blanco P,
Carrascosa JM, Ros M, Andrés A. Tissue-specific
effects of central leptin on the expression of
genes involved in lipid metabolism in liver and
white adipose tissue. Endocrinology. 2007;148(12):
5604–5610.
92. Hamrick MW, Della Fera MA, Choi YH, Hartzell D,
Pennington C, Baile CA. Injections of leptin into rat
ventromedial hypothalamus increase adipocyte
apoptosis in peripheral fat and in bone marrow. Cell
Tissue Res. 2007;327(1):133–141.
93. Veldhuis-Vlug AG, Rosen CJ. Clinical implications of
bone marrow adiposity. J Intern Med. 2018;283(2):
121–139.
94. Schlienger RG, Kraenzlin ME, Jick SS, Meier CR. Use
of beta-blockers and risk of fractures. JAMA. 2004;
292(11):1326–1332.
95. Rejnmark L, Vestergaard P, Mosekilde L. Treatment
with beta-blockers, ACE inhibitors, and calcium-
channel blockers is associated with a reduced
fracture risk: a nationwide case-control study.
J Hypertens. 2006;24(3):581–589.
96. de Vries F, Souverein PC, Cooper C, Leufkens HGM,
van Staa TP. Use of beta-blockers and the risk of
hip/femur fracture in the United Kingdom and The
Netherlands. Calcif Tissue Int. 2007;80(2):69–75.
97. Yang S, Nguyen ND, Center JR, Eisman JA, Nguyen
TV. Association between beta-blocker use and
fracture risk: the Dubbo Osteoporosis Epidemiology
Study. Bone. 2011;48(3):451–455.
98. Reid IR, Gamble GD, Grey AB, Black DM, Ensrud KE,
Browner WS, Bauer DC. beta-blocker use, BMD, and
fractures in the study of osteoporotic fractures.
J Bone Miner Res. 2005;20(4):613–618.
99. Levasseur R, Dargent-Molina P, Sabatier JP, Marcelli
C, Bréart G. Beta-blocker use, bone, mineral density,
and fracture risk in older women: results from the
Epidemiologie de l’Osteoporose Prospective Study.
J Am Geriatr Soc. 2005;53(3):550–552.
100. Rejnmark L, Vestergaard P, Kassem M, Christoffersen
BR, Kolthoff N, Brixen K, Mosekilde L. Fracture risk in
perimenopausal women treated with beta-blockers.
Calcif Tissue Int. 2004;75(5):365–372.
101. Reid IR, Lucas J, Wattie D, Horne A, Bolland M,
Gamble GD, Davidson JS, Grey AB. Effects of a
beta-blocker on bone turnover in normal
postmenopausal women: a randomized con-
trolled trial. J Clin Endocrinol Metab. 2005;90(9):
5212–5216.
102. Wilding JP, Gilbey SG, Bailey CJ, Batt RA, Williams G,
Ghatei MA, Bloom SR. Increased neuropeptide-Y
messenger ribonucleic acid (mRNA) and decreased
neurotensin mRNA in the hypothalamus of the
958 Reid et al Effects of Leptin on the Skeleton
obese (ob/ob) mouse. Endocrinology. 1993;132(5):
1939–1944.
103. Baldock PA, Lee NJ, Driessler F, Lin S, Allison S,
Stehrer B, Lin EJ, Zhang L, Enriquez RF, Wong IP,
McDonald MM, During M, Pierroz DD, Slack K, Shi
YC, Yulyaningsih E, Aljanova A, Little DG, Ferrari SL,
Sainsbury A, Eisman JA, Herzog H. Neuropeptide Y
knockout mice reveal a central role of NPY in the
coordination of bone mass to body weight. PLoS
One. 2009;4(12):e8415.
104. Wong IP, Nguyen AD, Khor EC, Enriquez RF, Eisman
JA, Sainsbury A, Herzog H, Baldock PA. Neuro-
peptide Y is a critical modulator of leptin’s regu-
lation of cortical bone. J Bone Miner Res. 2013;28:
886–898.
105. Hamrick MW, Ding KH, Ponnala S, Ferrari SL,
Isales CM. Caloric restriction decreases cortical
bone mass but spares trabecular bone in the
mouse skeleton: implications for the regulation of
bone mass by body weight. J Bone Miner Res. 2008;
23:870–878.
106. Walther DJ, Peter JU, Bashammakh S, Hörtnagl H,
Voits M, Fink H, Bader M. Synthesis of serotonin
by a second tryptophan hydroxylase isoform. Sci-
ence. 2003;299(5603):76.
107. Yadav VK, Oury F, Suda N, Liu ZW, Gao XB,
Confavreux C, Klemenhagen KC, Tanaka KF,
Gingrich JA, Guo XE, Tecott LH, Mann JJ, Hen R,
Horvath TL, Karsenty G. A serotonin-dependent
mechanism explains the leptin regulation of bone
mass, appetite, and energy expenditure. Cell. 2009;
138(5):976–989.
108. Yadav VK, Oury F, Tanaka KF, Thomas T, Wang Y,
Cremers S, Hen R, Krust A, Chambon P, Karsenty G.
Leptin-dependent serotonin control of appetite:
temporal specificity, transcriptional regulation, and
therapeutic implications [published correction
appears in J Exp Med. 2011;208(2):413]. J Exp Med.
2011;208(1):41–52.
109. Cornish J, Callon KE, Bava U, Lin C, Naot D, Hill BL,
Grey AB, Broom N, Myers DE, Nicholson GC, Reid IR.
Leptin directly regulates bone cell function in vitro
and reduces bone fragility in vivo. J Endocrinol. 2002;
175(2):405–415.
110. Lee YJ, Park JH, Ko JS, Kim HM. Expression of signal-
transducing leptin receptors on rat osteoblasts
indicates a direct involvement of leptin in the
regulation of bone formation. J Bone Miner Res.
2001;16(suppl 1):S495.
111. Enjuanes A, Supervı́a A, Nogués X, Dı́ez-Pérez A.
Leptin receptor (OB-R) gene expression in human
primary osteoblasts: confirmation. J Bone Miner Res.
2002;17(6):1135 author reply 1136.
112. Hess R, Pino AM, Rı́os S, Fernández M, Rodrı́guez JP.
High affinity leptin receptors are present in human
mesenchymal stem cells (MSCs) derived from
control and osteoporotic donors. J Cell Biochem.
2005;94(1):50–57.
113. Sufang C, Nemoto K, Kurose R, Kobayashi N, Kubo
K, Itabashi A. Different expression of leptin recep-
tor variants in MC3T3-E1 osteoblastic cells and
ATDC-5 chondroblastic cells. J Bone Miner Res. 2000;
15(suppl 1):S466.
114. Matic I, Matthews BG, Wang X, Dyment NA,
Worthley DL, Rowe DW, Grcevic D, Kalajzic I.
Quiescent bone lining cells are a major source of
osteoblasts during adulthood. Stem Cells. 2016;
34(12):2930–2942.
115. Gordeladze JO, Drevon CA, Syversen U, Reseland JE.
Leptin stimulates human osteoblastic cell pro-
liferation, de novo collagen synthesis, and min-
eralization: impact on differentiation markers,
apoptosis, and osteoclastic signaling. J Cell Biochem.
2002;85(4):825–836.
116. Lee YJ, Park JH, Ju SK, You KH, Ko JS, Kim HM. Leptin
receptor isoform expression in rat osteoblasts and
their functional analysis. FEBS Lett. 2002;528(1–3):
43–47.
117. Burguera B, Brunetto A, Garcia-Ocana A, Teijeiro R,
Esplen J, Thomas T, Couce ME, Zhao A. Leptin
increases proliferation of human steosarcoma cells
through activation of PI(3)-K and MAPK pathways.
Med Sci Monit. 2006;12(11):BR341–BR349.
118. Iwaniec UT, Shearon CC, Heaney RP, Cullen DM,
Yee JA. Leptin increases number of bone nodules
in vitro. Bone. 1998;13(5, suppl):S212.
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
119. Thomas T, Gori F, Khosla S, Jensen MD, Burguera B,
Riggs BL. Leptin acts on human marrow stromal
cells to enhance differentiation to osteoblasts and
to inhibit differentiation to adipocytes. Endocri-
nology. 1999;140(4):1630–1638.
120. Zhang J, Li T, Xu L, Li W, Cheng M, Zhuang J, Chen Y,
Xu W. Leptin promotes ossification through mul-
tiple ways of bone metabolism in osteoblast: a pilot
study. Gynecol Endocrinol. 2013;29(8):758–762.
121. Grundberg E, Brändström H, Lam KCL, Gurd S, Ge B,
Harmsen E, Kindmark A, Ljunggren O, Mallmin H,
Nilsson O, Pastinen T. Systematic assessment of the
human osteoblast transcriptome in resting and
induced primary cells. Physiol Genomics. 2008;33(3):
301–311.
122. Khan SN, DuRaine G, Virk SS, Fung J, Rowland DJ,
Reddi AH, Lee MA. The temporal role of leptin
within fracture healing and the effect of local ap-
plication of recombinant leptin on fracture healing.
J Orthop Trauma. 2013;27(11):656–662.
123. Beil FT, Barvencik F, Gebauer M, Beil B, Pogoda P,
Rueger JM, Ignatius A, Schinke T, Amling M. Effects
of increased bone formation on fracture healing in
mice. J Trauma. 2011;70(4):857–862.
124. Holloway WR, Collier FM, Aitken CJ, Myers DE,
Hodge JM, Malakellis M, Gough TJ, Collier GR,
Nicholson GC. Leptin inhibits osteoclast generation.
J Bone Miner Res. 2002;17(2):200–209.
125. Burguera B, Hofbauer LC, Thomas T, Gori F, Evans
GL, Khosla S, Riggs BL, Turner RT. Leptin reduces
ovariectomy-induced bone loss in rats. Endocri-
nology. 2001;142(8):3546–3553.
126. Lamghari M, Tavares L, Camboa N, Barbosa MA.
Leptin effect on RANKL and OPG expression in
MC3T3-E1 osteoblasts. J Cell Biochem. 2006;98(5):
1123–1129.
127. Maor G, Rochwerger M, Segev Y, Phillip M. Leptin
acts as a growth factor on the chondrocytes of
skeletal growth centers. J Bone Miner Res. 2002;17(6):
1034–1043.
128. Gat-Yablonski G, Shtaif B, Phillip M. Leptin stim-
ulates parathyroid hormone related peptide ex-
pression in the endochondral growth plate. J Pediatr
Endocrinol Metab. 2007;20(11):1215–1222.
129. Hamrick MW, Herberg S, Arounleut P, He HZ,
Shiver A, Qi RQ, Zhou L, Isales CM, Mi Q-S. The
adipokine leptin increases skeletal muscle mass and
significantly alters skeletal muscle miRNA expres-
sion profile in aged mice. Biochem Biophys Res
Commun. 2010;400(3):379–383.
130. Liu C, Grossmann A, Bain S, Strachan M, Puemer D,
Bailey C, Humes J, Lenox J, Yamamoto G, Sprugel K,
Kuijper J, Weigle S, Dumam D, Moore E. Leptin
stimulates cortical bone formation in obese (ob/ob)
mice. J Bone Miner Res. 1997;12(suppl 1):S115.
131. Gat-Yablonski G, Ben-Ari T, Shtaif B, Potievsky O,
Moran O, Eshet R, Maor G, Segev Y, Phillip M.
Leptin reverses the inhibitory effect of caloric re-
striction on longitudinal growth. Endocrinology.
2004;145(1):343–350.
132. Martin A, de Vittoris R, David V, Moraes R, Bégeot
M, Lafage-Proust MH, Alexandre C, Vico L, Thomas
Endocrine Reviews, December 2018, 39(6):938–959

T. Leptin modulates both resorption and formation
while preventing disuse-induced bone loss in tail-
suspended female rats. Endocrinology. 2005;146(8):
3652–3659.
133. Martin A, David V, Malaval L, Lafage-Proust MH,
Vico L, Thomas T. Opposite effects of leptin
on bone metabolism: a dose-dependent balance
related to energy intake and insulin-like growth
factor–I pathway. Endocrinology. 2007;148(7):
3419–3425.
134. Baek K, Bloomfield SA. Beta-adrenergic blockade
and leptin replacement effectively mitigate
disuse bone loss. J Bone Miner Res. 2009;24(5):
792–799.
135. Bertoni L, Ferretti M, Cavani F, Zavatti M, Resca E,
Benelli A, Palumbo C. Leptin increases growth of
primary ossification centers in fetal mice. J Anat.
2009;215(5):577–583.
136. Stunes AK, Westbroek I, Gordeladze JO, Gustafsson
BI, Reseland JE, Syversen U. Systemic leptin ad-
ministration in supraphysiological doses maintains
bone mineral density and mechanical strength
despite significant weight loss. Endocrinology. 2012;
153(5):2245–2253.
137. Hamrick MW, Ding KH, Ponnala S, Ferrari SL, Isales
CM. Caloric restriction decreases cortical bone
mass but spares trabecular bone in the mouse
skeleton: implications for the regulation of bone
mass by body weight. J Bone Miner Res. 2008;23(6):
870–878.
138. Iwaniec UT, Dube MG, Boghossian S, Song H,
Helferich WG, Turner RT, Kalra SP. Body mass in-
fluences cortical bone mass independent of leptin
signaling. Bone. 2009;44(3):404–412.
139. Moran SA, Patten N, Young JR, Cochran E, Sebring N,
Reynolds J, Premkumar A, Depaoli AM, Skarulis MC,
Oral EA, Gorden P. Changes in body composition in
patients with severe lipodystrophy after leptin re-
placement therapy. Metabolism. 2004;53(4):513–519.
doi: 10.1210/er.2017-00226
140. Welt CK, Chan JL, Bullen J, Murphy R, Smith P,
DePaoli AM, Karalis A, Mantzoros CS. Recombinant
human leptin in women with hypothalamic
amenorrhea. N Engl J Med. 2004;351(10):987–997.
141. Chou SH, Chamberland JP, Liu X, Matarese G, Gao
C, Stefanakis R, Brinkoetter MT, Gong H, Arampatzi
K, Mantzoros CS. Leptin is an effective treatment
for hypothalamic amenorrhea. Proc Natl Acad Sci
USA. 2011;108(16):6585–6590.
142. Conroy R, Girotra M, Shane E, McMahon DJ,
Pavlovich KH, Leibel RL, Rosenbaum M, Korner J.
Leptin administration does not prevent the bone
mineral metabolism changes induced by weight
loss. Metabolism. 2011;60(9):1222–1226.
143. Sienkiewicz E, Magkos F, Aronis KN, Brinkoetter
M, Chamberland JP, Chou S, Arampatzi KM, Gao
C, Koniaris A, Mantzoros CS. Long-term metre-
leptin treatment increases bone mineral density
and content at the lumbar spine of lean hypo-
leptinemic women. Metabolism. 2011;60(9):
1211–1221.
144. Foo J-P, Polyzos SA, Anastasilakis AD, Chou S,
Mantzoros CS. The effect of leptin replacement on
parathyroid hormone, RANKL-osteoprotegerin axis,
and Wnt inhibitors in young women with hypo-
thalamic amenorrhea. J Clin Endocrinol Metab. 2014;
99(11):E2252–E2258.
145. Maness LM, Kastin AJ, Farrell CL, Banks WA. Fate
of leptin after intracerebroventricular injection
into the mouse brain. Endocrinology. 1998;139(11):
4556–4562.
146. Trotter-Mayo RN, Roberts MR. Leptin acts in the
periphery to protect thymocytes from glucocorticoid-
mediated apoptosis in the absence of weight loss.
Endocrinology. 2008;149(10):5209–5218.
147. Otukonyong EE, Dube MG, Torto R, Kalra PS, Kalra
SP. Central leptin differentially modulates ultradian
secretory patterns of insulin, leptin and ghrelin
independent of effects on food intake and body
weight. Peptides. 2005;26(12):2559–2566.
https://academic.oup.com/edrv
REVIEW
148. Cornish J, Grey A, Callon KE, Naot D, Hill BL, Lin
CQX, Balchin LM, Reid IR. Shared pathways of
osteoblast mitogenesis induced by amylin, adre-
nomedullin, and IGF-1. Biochem Biophys Res Com-
mun. 2004;318(1):240–246.
149. Cornish J, Callon KE, Bava U, Watson M, Xu X, Lin
JM, Chan VA, Grey AB, Naot D, Buchanan CM,
Cooper GJS, Reid IR. Preptin, another peptide
product of the pancreatic beta-cell, is osteogenic
in vitro and in vivo. Am J Physiol Endocrinol Metab.
2007;292(1):E117–E122.
Downloaded from https://academic.oup.com/edrv/article-abstract/39/6/938/5088036 by Research 4 Life user on 22 November 2018
150. Cornish J, Callon KE, Reid IR. Insulin increases his-
tomorphometric indices of bone formation in vivo.
Calcif Tissue Int. 1996;59(6):492–495.
151. Morroni M, De Matteis R, Palumbo C, Ferretti M,
Villa I, Rubinacci A, Cinti S, Marotti G. In vivo leptin
expression in cartilage and bone cells of growing
rats and adult humans. J Anat. 2004;205(4):291–296.
Acknowledgments
Financial Support: Supported by the Health Research
Council of New Zealand.
Correspondence and Reprint Requests: Ian R. Reid,
MD, Faculty of Medical and Health Sciences, University of
Auckland, Private Bag 92019, Auckland 1132, New Zealand.
E-mail: i.reid@auckland.ac.nz.
Disclosure Summary: The authors have nothing to
disclose.
Abbreviations
BMD, bone mineral density; BMI, body mass index; CART,
cocaine- and amphetamine-regulated transcript; CNS, cen-
tral nervous system; CTX, C-telopeptide of type I collagen;
FGF23, fibroblast growth factor-23; ICV, intracerebroventricular;
LepRb, long form of the leptin receptor; NPY, neuropeptide Y;
SNS, sympathetic nervous system; Tph, tryptophan hydroxylase;
UCP1, uncoupling protein 1.
959