Historically, obesity was thought to be advantageous for maintaining healthy bones due to the greater bone mineral density observed in overweight individuals. However, recent observations of increased fracture in some obese individuals have led to concern that common metabolic complications of obesity, such as type 2 diabetes, metabolic syndrome, impaired glucose tolerance, insulin resistance, hyperglycemia, and inflammation may be associated with poor bone health. In support of this hypothesis, greater visceral fat, a hallmark of insulin resistance and metabolic syndrome, is associated with lower bone mineral density. Research is needed to determine if and how visceral fat and/or poor metabolic health are causally associated with bone health. Clinicians should consider adding a marker metabolic health, such as waist circumference or fasting plasma glucose concentration, to other known risk factors for osteoporosis and fracture. © 2013 The International Society for Clinical Densitometry.