New review highlights impact of diabetes on bone health and fracture risk

A landmark narrative review published by the Bone and Diabetes Working Group of the  International Osteoporosis Foundation (IOF) Committee of Scientific Advisors reveals critical insights into how diabetes mellitus alters bone microarchitecture and influences fracture risk.

The paper, titled "Bone microstructure and TBS in diabetes: what have we learned? A narrative review", summarizes research into the skeletal complications of diabetes. Despite normal or elevated bone mineral density (BMD) in people with type 2 diabetes (T2DM), these individuals face a significantly increased risk of fractures, which poses a major clinical paradox.

The authors explain that while type 1 diabetes (T1DM) is associated with reduced BMD and decreased trabecular microarchitecture, T2DM presents more complex challenges. High-resolution imaging studies show that patients with T2DM often have greater trabecular bone, consistent with higher BMD. Yet they remain at high risk of fracture, which could be partially explained by the greater porosity measured in their cortical bone. In both types of diabetes, alterations to the bone microstructure appear to be more pronounced at advanced stages of the disease. 

To resolve this inconsistency, the review examines the role of the trabecular bone score (TBS), a novel texture measure derived from lumbar spine dual-energy x-ray absorptiometry (DXA), that provides indirect information about bone microarchitecture. TBS is often reduced in individuals with diabetes, offering a potential explanation for increased fragility despite normal BMD. However, the authors caution that excess abdominal fat—a common feature of T2DM—can artificially lower TBS values under the current algorithm, for which an updated version is being developed and implemented. 

“Lower TBS values in people with T2DM may not necessarily indicate deteriorated bone structure, but rather reflect technical limitations in the measurement,” said lead author and Chair of the IOF Bone and Diabetes Working Group, Professor Serge Ferrari of the University Hospitals of Geneva. “This is especially important for fracture risk prediction and treatment decisions.”

The review underscores the need for updated diagnostic tools, including a revised TBS algorithm that accounts for abdominal tissue thickness, which may more accurately reflect bone quality in individuals with central obesity, a hallmark of T2DM.

Key findings include:

• T1DM is linked with decreased trabecular and cortical bone parameters. The decrease in cortical bone is more pronounced in those with microvascular disease, correlating with increased fracture risk.
• T2DM patients show preserved or increased BMD and trabecular bone parameters but paradoxically higher fracture rates.
• Cortical porosity and changes in bone material properties—possibly due to advanced glycation end-products (AGEs)—may underlie this fragility.
• TBS, when used alongside BMD and FRAX®, improves fracture risk prediction in T2DM.

The authors also advocate for the integration of updated TBS algorithms adjusting for tissue thickness. They call for more longitudinal studies and greater clinical awareness of diabetic bone disease in routine practice and fracture risk assessments.

Professor Eugene McCloskey, Chair of the IOF Committee of Scientific Advisors, stated: 

“This paper represents a collaborative effort by international experts, offering new clinical guidance for managing skeletal health in the rapidly growing global population with diabetes. Given the compelling evidence presented, we urge clinicians to take proactive steps to recognize, assess, and manage the often underestimated fracture risk in patients living with diabetes. This is especially critical for individuals with type 2 diabetes mellitus, where conventional diagnostic tools may fail to reflect the true extent of skeletal vulnerability."

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Reference:
Ferrari, S., Akesson, K. E., Al-Daghri, N., Biver, E., Chandran, M., Chevalley, T., Josse, R. G., Kendler, D. L., Lane, N. E., Makras, P., Meier, C., Mithal, A., Suzuki, A., Vasikaran, S., Pierroz, D. D., Leslie, W. D., & International Osteoporosis Foundation Committee of Scientific Advisors Working Group on Bone and Diabetes. (2025). Bone microstructure and TBS in diabetes: What have we learned? A narrative review. Osteoporosis International. https://doi.org/10.1007/s00198-025-07495-0
 

About IOF
The International Osteoporosis Foundation (IOF) is the world's largest nongovernmental organization dedicated to the prevention, diagnosis and treatment of osteoporosis and related musculoskeletal diseases. IOF’s network includes membership committees comprised of scientific experts, 340 patient, medical societies, and universities in more than 150 countries, as well as over 1100 Fracture Liaison Services in all regions of the world. The IOF network is united in its mission to prioritize bone health and fracture prevention, striving toward a shared vision of a world free from fragility fractures, where healthy mobility is a reality for all. @iofbonehealth
Websites: www.osteoporosis.foundation ; www.capturethefracture.org ; www.worldosteoporosisday.org ; www.buildbetterbones.org