The Relationship Between Glucose Metabolism, Metabolic Syndrome, and Bone-Specific Alkaline Phosphatase: A Structural Equation Modeling Approach

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Serum alkaline phosphatase plays a role in vascular calcification. It is found in various tissues, whereas bone-specific alkaline phosphatase (BAP) more specifically reflects mineral metabolism. The relationship of serum alkaline phosphatase (total and bone-specific) with diabetes and metabolic syndrome (MetS), 2 major risk factors of vascular calcification, is largely unknown.


We aimed to investigate the relationships between glucose metabolism, components of the MetS, and alkaline phosphatase.

Design and Setting:

This was a cross-sectional study of a nationally representative sample of the U.S. population in 1999 through 2004.


Participants were 3773 nondiabetic participants of the National Health and Nutrition Examination Survey 1999–2004.

Main Outcome Measures:

We measured serum BAP and total alkaline phosphatase.


In multivariable linear regression, updated homeostasis model assessment (HOMA2) for insulin resistance (β = 0.068), HOMA2 for β-cell function (β = 0.081), insulin (β = 0.065), mean arterial pressure (β = 0.15), and high-density lipoprotein (HDL)-cholesterol (β = 0.209) were positively associated with BAP, whereas HOMA2 for insulin sensitivity (β = −0.065) was negatively associated with BAP. On the other hand, only mean arterial pressure and HDL-cholesterol were significantly associated with total alkaline phosphatase. Moreover, a structural equation model revealed that hypertension, low HDL, and insulin resistance had significant direct effects on serum BAP levels, whereas obesity and inflammation might have indirect effects on serum BAP levels. The overall model showed very good fit to the data (comparative fit index = 0.995, root mean square error of approximation = 0.037, and standardized root mean square residual = 0.006).


Glucose metabolism and MetS are significantly related to serum BAP levels. How BAP mediates vascular calcification in diabetes and MetS warrants further studies.

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