Diabetes and bone health

Diabetes affects bone in two different ways depending on the type. In type 1 diabetes, low insulin and IGF-1 levels impair the cells that build bone, and the autoimmune inflammation involved in the disease adds to the damage. This leads to clearly lower bone mineral density and a sharply higher risk of hip fracture compared to people without diabetes.

Type 2 diabetes is trickier: bone density often looks normal or even above average, because higher insulin levels can stimulate bone-building cells and extra body weight adds helpful mechanical loading. Yet fracture risk is still meaningfully increased. The missing piece is bone quality, not quantity—advanced glycation end-products build up in the collagen matrix over years of elevated blood sugar, making bone stiffer and less able to absorb energy before breaking.

This is why standard bone density scans can be misleading in type 2 diabetes, and why standard fracture risk calculators may underestimate the true risk. Trabecular bone score, a measure of bone texture taken from the same DEXA scan, often shows reduced microarchitecture quality in diabetes even when the density number itself looks fine. If you have diabetes, talk with your doctor about whether this extra context belongs in your fracture risk conversation.