Bone loss doesn’t explain higher fracture risk in T2D

Clinical takeaway: Do not assume relatively preserved bone density means low fracture risk in older adults with type 2 diabetes. Fracture prevention should also consider factors beyond bone loss, including fall risk and other clinical contributors to skeletal fragility.

Older adults with type 2 diabetes have a puzzling skeletal risk profile: despite often having higher bone mineral density, they experience more fractures. New longitudinal data suggest that accelerated deterioration in bone density, microarchitecture, or strength does not explain this paradox.

The Framingham Study analysis included 769 adults with a mean age of 67 years who underwent high-resolution peripheral quantitative CT imaging of the radius and tibia twice, approximately eight years apart. At baseline, 57% had normoglycemia, 31% had prediabetes, and 12% had type 2 diabetes.

Changes in cortical and trabecular bone density, microarchitecture, and estimated strength were similar across glycemic groups. Results also did not meaningfully differ according to diabetes medication use, disease duration, or A1c.

For example, cortical volumetric bone mineral density at the radius declined by 1.50% in participants with type 2 diabetes, 1.96% in those with prediabetes, and 2.42% in those with normoglycemia, with no statistically significant differences between groups.

The findings shift attention toward other explanations for excess fractures in type 2 diabetes rather than accelerated age-related bone loss alone. Future research will need to clarify which factors account for this added vulnerability and how they might improve fracture-risk assessment in patients whose bone density may appear reassuring.

“Although people with type 2 diabetes often have denser bones, they are still more likely to suffer fractures,” said senior author Elizabeth Samelson, PhD, of the Hinda and Arthur Marcus Institute for Aging Research. “This paradox suggests that bone density alone does not tell the whole story and highlights the importance of understanding other factors that influence bone strength and fracture risk.”

Source: Dufour AB, et al. (2026 Aug 5) Diabetes Care. Type 2 diabetes and longitudinal changes in cortical and trabecular bone density, microarchitecture, and strength: The Framingham Study