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August 2022, Volume 72, Issue 8

Primary Care Diabetes

Osteoporosis and diabetes: The dual pandemics

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital & BRIDE, Karnal, India. )
Ameya Joshi  ( Department of Endocrinology & Diabetes, Bhaktivedanta Hospital and Research Institute, Mumbai, )
Nitin Kapoor  ( Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore (TN) -632004, India, and Non Communicable Disease Unit, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia. )


Bone health is an important, but neglected aspect of diabetes care. People with type 1 diabetes are known to have a lower bone mineral density (BMD), which put them at a greater risk of osteoporosis and fractures. While BMD in those with type 2 diabetes is often misleading, multiple factors operate to increase the risk of falls and fractures in them. This article provides an overview of osteoporosis in diabetes. It proposes a LEMON mnemonic to understand the multifaceted aspects of bone care.


Keywords: Bone health, FRAX, osteopenia, osteoporosis, Vitamin D.







Osteoporosis is a condition in which bones become weak and brittle. Diabetes is an important cause of secondary osteoporosis. People with type 1 diabetes are more prone to osteoporosis while data for type 2 diabetes is emerging.1 Though osteoporosis is diagnosed and defined by bone mineral density (BMD) levels, bone health is also linked with suboptimal bone quality. Even though type 2 diabetes may be associated with normal or increased BMD, the quality or structure of bone is inadequate to prevent fractures.2 The high prevalence of osteoporosis in people with diabetes implies that it should be viewed as an important viscero-metabolic complication of the syndrome. Moreover, the very high mortality following a hip fracture, which indeed is the most dreaded complication of osteoporosis, is preventable by early screening and initiation of cost-effective treatment.3




Multiple factors, both skeletal and non-skeletal, contribute to the pathogenesis of falls and fractures in diabetes. These are listed in Table-1. All these factors are common in people with diabetes and operate in tandem to worsen bone mass and/or quality, as well as increase the propensity to fracture. In addition to these factors, in those with Type 1 diabetes, insulin deficiency further contributes to poor bone health due to the lack of its anabolic actions on bone mineral density.4




Screening and Diagnosis


A comprehensive metabolic bone health assessment, at regular intervals, is indicated for all people with diabetes. Apart from clinical and biochemical assessment, a simple risk using the validated country specific FRAX tool can be used. FRAX does not include diabetes as a risk factor. However, some experts feel that for people with diabetes we could include the rheumatoid arthritis box instead of diabetes to get a more realistic opinion of their fracture risk with FRAX. Other methods would include to increase the age by 5 years or reducing the t score by 0.5 SD.5 Individuals who are at high risk of osteoporosis, e.g., postmenopausal women, hypogonadal men, and those on long term glucocorticoid therapy, should undergo dual energy X-ray absorptiometry (DEXA) scan to confirm the diagnosis. Where facilities are available it is recommended that trabecular bone score may be used to assess the bone microarchitecture and fracture risk in people living with diabetes.6

Standard principles of care should be followed while screening, diagnosing and monitoring patients with low BMD. It must be reinforced that bone health should be given the same importance as microvascular, macrovascular and other viscero-metabolic complications in diabetes management.


Management and Prevention


The prevention and management of osteoporosis needs a multifaceted approach that is possible only through teamwork. Table-2 captures a pragmatic attitude towards holistic promotion of bone health. The LEMON rubric reminds us of the need to address bone health through an all-inclusive spectrum, which views prevention and management as parts of the same approach.7 Anti-osteoporotic therapy and vitamin D therapy have been discussed at length earlier.





Bone health is often an under-recognized problem in people living with diabetes. Given the high mortality associated with fragility fractures, easy screening and available of cost-effective treatment, it should become an integral part of diabetes management. Emphasis should be laid on preventing falls and fractures incorporating by LEMON approach in the daily practice.




1.      Kaur P, Anjana RM, Tandon N, Singh MK, Mohan V, Mithal A. Increased prevalence of self-reported fractures in Asian Indians with diabetes: Results from the ICMR-INDIAB population based cross-sectional study. Bone. 2020;135:115323.

2.      Farooqui KJ, Mithal A, Kerwen AK, Chandran M. Type 2 diabetes and bone fragility- An under-recognized association. Diabetes Metab Syndr. 2021;15:927-35.

3.      Bhadada SK, Chadha M, Sriram U, Pal R, Paul TV, Khadgawat R, et al. The Indian Society for Bone and Mineral Research (ISBMR) position statement for the diagnosis and treatment of osteoporosis in adults. Arch Osteoporos. 2021;16:102.

4.      Paul J, Devarapalli V, Johnson JT, Cherian KE, Jebasingh FK, Asha HS, et al. Do proximal hip geometry, trabecular microarchitecture, and prevalent vertebral fractures differ in postmenopausal women with type 2 diabetes mellitus? A cross-sectional study from a teaching hospital in southern India. Osteoporos Int. 2021;32:10.1007/s00198-021-05855-0

5.      Leslie WD, Johansson H, McCloskey EV, Harvey NC, Kanis JA, Hans D. Comparison of Methods for Improving Fracture Risk Assessment in Diabetes: The Manitoba BMD Registry. J Bone Miner Res. 2018;33:1923-30.

6.      Anderson PA, Freedman BA, Brox WT, Shaffer WO. Osteoporosis: Recent Recommendations and Positions of the American Society for Bone and Mineral Research and the International Society for Clinical Densitometry. J Bone Joint Surg Am. 2021;103:741-7.

7.      Kalra S, Kalhan A, Dhingra A, Kapoor N. Management of late-onset hypogonadism: person-centred thresholds, targets, techniques and tools. J R Coll Physicians Edinb. 2021;51:79-84.

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