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Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a topic covered in the 5-Minute Clinical Consult.

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  • Characterized by calcification and ossification of soft tissues, primarily ligaments and entheses; most commonly in the spine, especially thoracic segments
  • Synonym(s): Forestier disease; vertebral ankylosing hyperostosis; ankylosing spondylitis (AS)
Geriatric Considerations
  • Diffuse idiopathic skeletal hyperostosis (DISH) is typically asymptomatic; it may, however, decrease spinal mobility and predispose patients to fractures after only mild trauma.
  • DISH and osteoarthritis (OA) may coexist. Both affect the same population (elderly and obese).
  • Bone mineral density (BMD) measurements obtained by dual energy x-ray absorptiometry (DEXA) and quantitative CT may not be accurate (falsely high) due to lumbar ossification/calcification in DISH.
  • DISH should be considered in elderly patients with unexplained respiratory distress or dysphagia (1).


  • Most common in elderly, obese males
  • Prevalence varies geographically.

Incidence increases with age and is higher in men.

  • Difficult to calculate due to variable classification criteria used across literature
  • United States: approximately 10% in people ≥50 years
  • Japan: 8.7%

Etiology and Pathophysiology

  • The etiology is unknown. Increased levels of insulin, insulin-like growth factor 1, and transforming growth factor-β1 are believed to stimulate osteoblasts and bone proliferation (1).
  • Low serum levels of bone formation inhibitors (e.g., bone morphogenetic protein 2 or Dickkopf-1 [DKK-1], an inhibitor of the Wnt pathway required for new bone formation) may also play a role in DISH and are associated with more severe spinal involvement (1).

Risk Factors

  • Age
  • Male gender
  • Increased BMI
  • Hypertension
  • Metabolic syndrome
  • Diabetes
  • Hyperuricemia
  • Dyslipidemia
  • Lumbar spondylosis and knee OA

General Prevention

Control modifiable risk factors and the associated metabolic diseases.

Commonly Associated Conditions

Metabolic derangements associated with DISH:

  • Obesity; large waist circumference
  • Diabetes; hyperinsulinemia/insulin resistance
  • Metabolic syndrome
  • Hypertension
  • Dyslipidemia
  • Hyperuricemia

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Stephens, Mark B., et al., editors. "Diffuse Idiopathic Skeletal Hyperostosis (DISH)." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_.
Diffuse Idiopathic Skeletal Hyperostosis (DISH). In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_. Accessed April 25, 2019.
Diffuse Idiopathic Skeletal Hyperostosis (DISH). (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_
Diffuse Idiopathic Skeletal Hyperostosis (DISH) [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 25]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Diffuse Idiopathic Skeletal Hyperostosis (DISH) ID - 1688208 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_ PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -