Bone fragility in diabetes: novel concepts and clinical implications

Increased fracture risk represents an emerging and severe complication of diabetes. The resulting prolonged immobility and hospitalisations can lead to substantial morbidity and mortality. In type 1 diabetes, bone mass and bone strength are reduced, resulting in up to a five-times greater risk of fractures throughout life. In type 2 diabetes, fracture risk is increased despite a normal bone mass. Conventional dual-energy x-ray absorptiometry might underestimate fracture risk, but can be improved by applying specific adjustments. Bone fragility in diabetes can result from cellular abnormalities, matrix interactions, immune and vascular changes, and musculoskeletal maladaptation to chronic hyperglycaemia. This Review summarises how the bone microenvironment responds to type 1 and type 2 diabetes, and the mechanisms underlying fragility fractures. We describe the value of novel imaging technologies and the clinical utility of biomarkers, and discuss current and future therapeutic approaches that protect bone health in people with diabetes.

Automated summary

Increased fracture risk is a serious complication of diabetes, leading to prolonged immobility and hospitalizations that can result in significant morbidity and mortality. In type 1 diabetes, bone mass and strength are reduced, leading to a five-fold increased risk of lifelong fractures. In type 2 diabetes, fracture risk is increased despite normal bone mass. The fragility of bones in diabetes can be attributed to cellular abnormalities, matrix interactions, immune and vascular changes, and musculoskeletal maladaptation to chronic hyperglycemia.