Introduction The complex interplay of chronic inflammation, malnutrition, and corticosteroid exposure places patients with inflammatory bowel disease (IBD) at higher risk for low bone mineral density (BMD) compared to the general population. As part of evidence-based health maintenance, BMD screening via dual-energy X-ray absorptiometry (DXA) is recommended for older adults and should be considered for individuals with high-risk comorbidities including chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation, diabetes, and obesity. Despite these guidelines, studies have consistently demonstrated underutilization of DXA screening within the higher risk IBD populations. This study aims to quantify DXA screening rates among these patients and identify risk factors contributing to screening underutilization. Methods In this single-center retrospective cohort study, electronic medical record (EMR) data were used to identify IBD patients aged ≥50 years or with ≥1 chronic comorbidity via International Classification of Diseases-10 (ICD-10) codes K50 (Crohn’s) and K51 (ulcerative colitis) from gastroenterology visits between 1/1/2018 and 12/31/2024. The primary outcomes were DXA scans ordered but not completed (DXA ordered) or completed during the study (DXR resulted). Logistic regression analysis was carried out to examine possible differences in groups with DXA ordered and DXA resulted, while controlling for demographics, comorbidities, and disease duration. Results A total of 1,161 patients met the age or comorbidity criteria (mean age 58.1 years, range 20–95; 48.7% male; 88.6% non-Hispanic white; 52.7% Crohn’s disease, 47.3% ulcerative colitis; 44.2% current/former smokers; 37.2% Medicare; 12.5% Medicaid/other). Comorbidities included autoimmune (19.7%), cardiopulmonary (17.3%), and metabolic disorders (57.7%). Among those with available data from EMR reports (n=257), the average disease duration was 22.8 years. Overall DXA order and completion rates were 31.2% and 27.2%, respectively. Regression analyses showed decreased odds of DXA orders in younger age groups (≤49 and 50–59 years) and males, with an increased odds of DXA orders in patients on Medicare and in those with metabolic disorders. Similar patterns were observed for completed DXA scans. In a sub-study (n=250) of those with disease-time available, a higher disease time-to-age ratio was linked to increased odds of DXA resulted. Conclusion DXA screening was lower in younger age groups, men, and among those with Medicaid insurance, while higher in Medicare patients and patients with metabolic comorbidities. These findings highlight important considerations for groups at greater risk for underutilization of DXA screening.