Type 2 Diabetes and Bone Health: The Hidden Fracture Risk

Does type 2 diabetes increase your risk of breaking a bone?

Yes — type 2 diabetes is linked to a higher chance of osteoporosis and fractures, even though it often isn't thought of as a "bone" condition. The Royal Osteoporosis Society states plainly that people with diabetes have a higher chance of osteoporosis and breaking a bone. Royal Osteoporosis Society, 2024

Putting numbers to it, a 2017 systematic review and meta-analysis found a pooled hip-fracture relative risk of 1.20 (95% CI 1.17–1.23) in type 2 diabetes, with any-fracture risk raised more modestly. The same analysis found insulin therapy carried a higher pooled fracture risk (RR 1.52), and that the association was stronger in people who had lived with diabetes for ten or more years. Therapeutics and Clinical Risk Management, 2017 Other meta-analyses have reported hip-fracture risk closer to 1.3×, so the honest picture is "around 1.2–1.3 times higher" rather than a single fixed figure.

Why can a "normal" DEXA scan be misleading if you have type 2 diabetes?

Because of the "diabetic bone paradox": people with type 2 diabetes often show normal or even elevated bone mineral density on DEXA, yet fracture more often than that density would predict. A 2024 clinical review put it directly: despite elevated BMD, individuals with type 2 diabetes are at an increased risk of fractures. Metabolism Open, 2024

The International Osteoporosis Foundation reached the same conclusion in a 2025 summary of its Bone and Diabetes Working Group review: despite normal or elevated bone density, people with type 2 diabetes face a significantly increased risk of fractures. International Osteoporosis Foundation, 2025 In practice, that means a DEXA number that looks reassuring can under-estimate true fracture risk in diabetes — a point the 2024 review makes explicitly about both DXA and FRAX. Metabolism Open, 2024 If you want a plain-English primer on what that scan actually measures, see our guide to what a DEXA scan shows.

Why does diabetes weaken bones even when density looks normal?

The key is bone quality — the internal structure and material of bone — rather than the amount of bone. Chronically high blood sugar drives a process called non-enzymatic glycation, in which advanced glycation end-products (AGEs) build up in the collagen of the bone matrix. That makes bone more brittle even when density readings stay normal. Metabolism Open, 2024

Alongside AGE accumulation, the IOF review points to increased cortical porosity — more tiny holes in the dense outer shell of bone — and other changes in bone material properties as likely reasons the skeleton becomes fragile despite a normal-looking scan. International Osteoporosis Foundation, 2025 Density tells you how much bone there is; it says little about how well that bone is put together — which is exactly where diabetes does its quiet damage.

What else raises fracture risk if you have type 2 diabetes?

Several factors stack on top of the bone-quality changes — and not all of them are about the bone itself. The 2024 review groups the contributors as prolonged hyperglycaemia, poorer glycaemic management, neuropathy-related falls, visual impairment, and certain medicines such as thiazolidinediones. Metabolism Open, 2024 The Royal Osteoporosis Society lists a similar set: reduced bone strength, increased falls, reduced muscle mass, diabetes lasting longer than five years, and some diabetes medicines such as pioglitazone. Royal Osteoporosis Society, 2024

UK guidance echoes this. NOGG 2024 states that in type 2 diabetes a longer duration of disease and insulin use are associated with increased fracture risk that is partly independent of BMD, and that some diabetes drugs — thiazolidinediones among them — also raise risk. National Osteoporosis Guideline Group (NOGG), 2024

Does the FRAX fracture risk calculator work well for people with type 2 diabetes?

Often not — FRAX tends to under-estimate fracture risk in type 2 diabetes, because it leans heavily on bone density, which can look deceptively normal. The 2024 review flags that DXA and FRAX may underestimate fracture risk in people with diabetes. Metabolism Open, 2024

To compensate, NOGG 2024 advises clinicians to adjust the calculation — specifically, to "enter yes in the rheumatoid arthritis input to FRAX" as a proxy for both type 1 and type 2 diabetes, because FRAX otherwise under-estimates their risk. National Osteoporosis Guideline Group (NOGG), 2024 This is a clinical adjustment your healthcare professional makes — it isn't something to self-calculate. Our explainer on fracture risk and FRAX walks through how the tool works and where its limits lie.

How can bone-quality monitoring help if you have type 2 diabetes?

Because standard density scans can miss diabetes-related fragility, a bone-quality signal can add useful context. In one study of 90 postmenopausal women with type 2 diabetes compared with 90 controls, REMS (Radiofrequency Echographic Multi Spectrometry) classified 47.0% of the diabetic women as osteoporotic, versus 28.0% by DXA; DXA density values ran higher in the diabetic women while REMS values ran lower. The authors concluded REMS may represent a useful approach to enhance the diagnosis of osteoporosis in patients with type 2 diabetes. Aging Clinical and Experimental Research, 2022

That single study shouldn't be read as REMS being diagnostically "better" than DEXA across the board — it's one 90-woman study, and DEXA remains the UK reference method for diagnosing osteoporosis. But it does illustrate the paradox in action: the scan that reads bone quality flagged fragility the density scan missed. For a fuller side-by-side of the two methods, see our REMS vs DEXA scan comparison.

Because REMS is radiation-free, it can be repeated safely, which makes it a practical way to establish a baseline and monitor your bones over time — complementing, never replacing, your GP and diabetes specialist care. You can read what's involved on our bone health assessment page.

How can you protect your bones if you have type 2 diabetes?

The foundations are the same ones that support good diabetes control, plus a plan to actually check on your bones. Weight-bearing and resistance exercise to build muscle and load the skeleton, adequate protein, calcium and vitamin D, not smoking, and moderating alcohol all help — and reducing falls (managing neuropathy, checking eyesight, sorting home hazards) matters just as much as the bone itself, given how many diabetes-related fractures start with a fall. Metabolism Open, 2024

The most concrete step is a professional risk review. The Royal Osteoporosis Society advises that people over 50 with diabetes and other risk factors should speak to their doctor about a fracture risk assessment. Royal Osteoporosis Society, 2024 Bring any previous scan results to that conversation, and remember that a normal DEXA on its own may not tell the whole story in diabetes — which is the entire reason bone-quality monitoring exists.

---

This article is part of our bone health series. If you take a glucose-lowering medication and want the bigger picture, see our medical conditions and bone health guides.