An estimated 422 million people worldwide are thought to have diabetes. Where diabetes is a chronic metabolic disease that impacts your blood sugar levels, osteoporosis is a condition that affects your bones. And osteoporosis is also common, affecting more than 200 million people across the globe. 

If you have diabetes, chances are you’re taking steps to manage blood sugar levels — but here’s why you should prioritize bone health, too.  

The Link Between Diabetes and Osteoporosis

People who have diabetes tend to have worse bone quality and an increased risk of fracture compared to those who aren’t living with this metabolic disorder. While this is true for both type 1 and type 2 diabetes, it’s particularly prevalent in type 1. 

Type 1 Diabetes and Osteoporosis

Type 1 diabetes typically starts at a young age when bone mass is still increasing. It’s thought that this leads to lower peak bone mass, or the maximum strength and density that bones reach, compared to the general population. As a result, this may increase the risk of developing osteoporosis down the line. 

 Type 2 Diabetes and Osteoporosis 

“There are all sorts of hypotheses as to why type 2 diabetes is associated with an increased risk of fracture,” says Kendall Ford Moseley, MD, Clinical Director of the Division of Endocrinology, Diabetes and Metabolism at the Johns Hopkins University School of Medicine. 

For starters, episodes of low blood sugar have been connected with an increased risk of falls and fracture. Though other factors, like diabetes medications and related comorbidities, may also play a role. 

Medications 

“Sometimes people who have type 2 diabetes are treated with medications that might increase the risk of fracture,” says Moseley.  

Research shows that options like thiazolidinediones (TZDs) can affect bone health and increase fracture risk, particularly in postmenopausal women. Certain SGLT2 inhibitors, such as canagliflozin, should be used with caution in those with a high risk of fractures. On the other hand, metformin — the gold standard type2 diabetes treatment — may provide protective benefits to bone health. 

Comorbidities

“Type 2 diabetes is also associated with other diseases, including kidney disease, vascular disease, neuropathy, retinopathy,” says Moseley. All of which can affect bone health and fracture risk. 

“Kidney disease and vascular disease can immediately impact bone health and cause bone loss,” says Moseley. For starters, type 2 diabetes and heart disease are known to co-exist. While cardiovascular disease and osteoporosis have many shared risk factors, including aging, smoking, and being sedentary, researchers are still trying to understand exactly how these two conditions are linked. However, studies have established a relationship between diabetic kidney disease and an increased risk of incident frailty. 

“Neuropathy or numbness of the feet can result in increased falls,” adds Moseley. In fact, findings from a 2020 analysis directly link diabetic neuropathy with an increased risk of developing osteoporosis or experiencing fragility fracture. 

“Additionally, retinopathy, which can reduce vision, can also increase falls and fracture,” notes Moseley. Findings from one Korean study also noted an associated between diabetic retinopathy and low bone mineral density in women with type 2 diabetes. 

Osteoporosis Risk Factors 

While diabetes and osteoporosis share some risk factors, other factors also play a role in the development of this bone condition. These can be broken into two groups: uncontrollable and controllable risk factors. 

Uncontrollable risk factors for osteoporosis include:  

  • Gender: Osteoporosis is more common in women, especially in perimenopausal women. 
  • Ethnicity: Osteoporosis is more common in Caucasian and Asian women. 
  • Age: The older you get, the higher your risk of developing osteoporosis. 
  • Family history: If an immediate family member, like a parent, has osteoporosis your risk of developing it increases. 

Controllable risk factors, or those you can modify, include: 

  • Medications: Aside from TZDs, medications you may take to treat other conditions, like steroids or anticonvulsants, may also contribute to osteoporosis. 
  • Diet: Low calcium and vitamin D intake may contribute to osteoporosis risk. 
  • Inactivity: Not exercising regularly, or being inactive, can weaken your bones. 
  • Weight: Being underweight (or having a small body frame) can impact bone health. 
  • Smoking: Smoking cigarettes makes you more prone to osteoporosis and bone fractures. 
  • Alcohol: Excessive alcohol consumption impacts how the body absorbs calcium and vitamin D, both of which are critical for healthy bone development. 

By familiarizing yourself with the many risk factors tied to osteoporosis, you can have an informed conversation with your health care provider about your personal risk and what you can do to protect your bones. 

Osteoporosis Symptoms  

Osteoporosis is sometimes referred to as a “silent” condition. That’s because it often has no symptoms.  

As it progresses, it can lead to symptoms like  

  • Back pain 
  • Sudden back pain 
  • Joint pain 
  • Changes in posture 
  • Stooping or loss of height 

But most people aren’t aware they have osteoporosis until they fracture or break a bone. This is especially true for people with type 2 diabetes, says Moseley. That’s why it’s so important to be aware of osteoporosis and take steps to protect your bone health. 

How to Manage Diabetes and Protect Your Bones 

“Luckily, a lot of the things that are recommended diabetes and blood glucose improvement are also recommended for those with osteoporosis,” says Moseley. Start with these strategies. 

Eat a Healthy, Nutritious Diet 

Diet plays an important role in diabetes management. Research also shows that poor dietary habits can contribute to the progression of osteoporosis — but following healthier eating habits may help decrease disease progression.  

Aim to eat a well-balanced diet focused on fruits, vegetables, fish, whole grains, and legumes. While more studies are needed to fully understand the impact diet may have on fracture risk in those with diabetes, “a number of diabetics are thought to be vitamin D deficient,” notes Moseley. Both calcium and vitamin D also play a role in preserving healthy bones, so plan to get plenty of these essential nutrients through your diet.

Women ages 50 and under and men ages 70 and under should aim to get 1,000 mg of calcium each day and increase intake to 1,200 mg each day once  women reach age 51 and men reach age 71. The recommended vitamin D intake is 400-800 IU a day for most adults under age 50, and 800-1,000 IU a day for those 50 and up. 

Stay Active and Maintain a Healthy Weight 

“Exercise is very critical for weight loss in diabetes,” says Moseley, emphasizing the importance of activities that promote muscle gain to combat any decreases in bone mass that may come with weight loss.  

Exercise is also a key strategy for improving bone health and preventing osteoporosis. “We encourage exercise in individuals with osteoporosis not only to promote healthy bone building, but also to prevent falls,” she adds.  

Plan to incorporate a mix of activities into your workout plan to manage diabetes and protect bone health. Research has found that resistance exercises in particular can help preserve both bone and muscle mass. Some evidence suggests that combining resistance exercises with weight-bearing aerobic activities may help prevent excessive bone loss in people who have type 2 diabetes.  

Quit Smoking 

Smoking can contribute to weakened bones and increase fracture risk. Research shows smoking also increases the risk of osteoporosis in people who have type 2 diabetes. Meanwhile, many people who smoke also partake in other unhealthy lifestyle habits that affect both diabetes and bone health, like decreased activity levels and poor diet. 

If you smoke, it’s best to quit. Findings from one study show that quitting may help increase bone mass previously lost due to smoking.  

Ask your doctor if you need help with quitting. You may benefit from the use of a smoking cessation aid. 

Moderate Alcohol Use 

Research shows that chronic, excessive alcohol consumption increases osteoporosis risk. Heavy drinking has also been linked with a decrease in bone density and weakened bones.  

What’s more, excessive alcohol consumption has also been linked to other lifestyle habits that affect bone health, including smoking and poor eating habits. 

If you do drink, be sure to so in moderation: That means one drink a day for women, and two for men. In fact, moderate alcohol consumption may help improve blood sugar management and insulin sensitivity. This doesn’t mean you should start drinking if you don’t already. 

When to Talk to Your Doctor About Bone Health 

Because there are often no symptoms of osteoporosis until a bone breaks, routine screening can help prevent osteoporosis. Screening is easy and only takes five to 10 minutes. Early detection can help you take proper steps to prevent fractures and promote bone health.  

Routine screening for osteoporosis should be done:  

  • After age 65 for women, 70 for men, or sooner depending on your personal risk factors 
  • Every one or two years, or more often depending on your health  
  • After a bone fracture in those over age 50 
  • When taking new medication associated with low bone mass or bone loss 

“In individuals with type 2 diabetes, bone mineral density testing is often normal — or it may be high or even just a bit reduced — and that can be falsely reassuring,” says Moseley. “We know that people with type 2 diabetes are at higher risk for fracture of the hip, spine, and periphery.”  

Talk to your doctor about osteoporosis at your next health exam. Make a plan to screen for the bone disease and account for all risk factors to help prevent bone fractures before they occur. 

This article was made possible with support from Amgen. 

Alsaadawi T. Smoking is Associated with Increased Risk of Osteoporosis in Diabetes Mellitus Patients. Journal of Bone Research and Reports. October 2016. https://bone.imedpub.com/smoking-is-associated-with-increased-risk-ofosteoporosis-in-diabetes-mellitus-patients.php?aid=18262.  

American Bone Health. How Often Should I Get Tested? https://americanbonehealth.org/bone-density/how-often-should-i-have-a-bone-density-test/.  

American Diabetes Association. Alcohol and Diabetes. https://diabetes.org/healthy-living/medication-treatments/alcohol-diabetes. 

Bone Health & Osteoporosis Foundation. Evaluation of Bone Health/Bone Density Testing.  https://www.bonehealthandosteoporosis.org/patients/diagnosis-information/bone-density-examtesting/.  

Bone Health & Osteoporosis Foundation. Food and Your Bones — Osteoporosis Nutrition Guidelines. https://www.bonehealthandosteoporosis.org/patients/treatment/nutrition/.  

Bone Health & Osteoporosis Foundation. Get the Facts on Calcium and Vitamin D. https://www.bonehealthandosteoporosis.org/patients/treatment/calciumvitamin-d/get-the-facts-on-calcium-and-vitamin-d/.  

Bone Health & Osteoporosis Foundation. Osteoporosis Exercise for Strong Bones. https://www.bonehealthandosteoporosis.org/patients/treatment/exercisesafe-movement/osteoporosis-exercise-for-strong-bones/.  

Centers for Disease Control and Prevention. Diabetes and Your Heart. https://www.cdc.gov/diabetes/library/features/diabetes-and-heart.html.  

Chao, CT, et al. Chronic kidney disease–related osteoporosis is associated with incident frailty among patients with diabetic kidney disease: a propensity score–matched cohort study. Osteoporosis International. February 2020. https://link.springer.com/article/10.1007/s00198-020-05353-9.  

Cleveland Clinic. When (and Why) Should I Start Screening for Osteoporosis?  https://health.clevelandclinic.org/when-and-why-should-i-start-screening-for-osteoporosis/.  

Faraj M, et al. The Impact of Diet on Bone and Fracture Risk in Diabetes. Current Osteoporosis Reports. February 2022. https://pubmed.ncbi.nlm.nih.gov/35201556/.  

Guja C, et al. Effect of type 2 diabetes medications on fracture risk. Annals of Translational Medicine. October 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861738/.  

Hong AR, et al. Effects of Resistance Exercise on Bone Health. Endocrinology and Metabolism (Seoul). December 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279907/.  

Jiang BC, et al. Weight Loss-Induced Reduction of Bone Mineral Density in Older Adults with Obesity. Journal of Nutrition in Gerontology and Geriatrics. Feb 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6480356/.  

Kiyota Y, et al. Smoking cessation increases levels of osteocalcin and uncarboxylated osteocalcin in human sera. Scientific Reports. October 2020. https://www.nature.com/articles/s41598-020-73789-4.  

Lim Y, et al. Association of bone mineral density and diabetic retinopathy in diabetic subjects: the 2008-2011 Korea National Health and Nutrition Examination Survey. Osteoporosis International. July 2016. doi: https://doi.org/10.1007/s00198-016-3527-5. 

Liu C, et al. Association between diabetic neuropathy and osteoporosis in patients: a systematic review and meta-analysis. Archives of Osteoporosis. August 2020. doi: https://doi.org/10.1007/s11657-020-00804-6. 

Mayo Clinic. Bone health: Tips to keep your bones healthy. https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/bone-health/art-20045060.  

Mayo Clinic. Osteoporosis. https://www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968.  

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Osteoporosis. https://www.niams.nih.gov/health-topics/osteoporosis. 

NIH National Institute on Alcohol Abuse and Alcoholism. Alcohol and Other Factors Affecting Osteoporosis Risk in Women. https://pubs.niaaa.nih.gov/publications/arh26-4/292-298.htm.  

NIH Osteoporosis and Related Bone Diseases National Resource Center. Exercise for Your Bone Health. https://www.bones.nih.gov/health-info/bone/bone-health/exercise/exercise-your-bone-health. 

NIH Osteoporosis and Related Bone Diseases National Resource Center. Smoking and Bone Health. https://www.bones.nih.gov/health-info/bone/osteoporosis/conditions-behaviors/bone-smoking.  

NIH Osteoporosis and Related Bone Diseases National Resource Center. What People With Diabetes Need to Know About Osteoporosis. https://www.bones.nih.gov/health-info/bone/osteoporosis/conditions-behaviors/diabetes.  

Interview with Kendall Ford Moseley, MD, Clinical Director of the Division of Endocrinology, Diabetes and Metabolism at the Johns Hopkins University School of Medicine. 

Sözen T, et al. An overview and management of osteoporosis. European Journal of Rheumatology. March 2017. doi: https://doi.org/10.5152/eurjrheum.2016.048.

Viggers R, et al. The Impact of Exercise on Bone Health in Type 2 Diabetes Mellitus-a Systematic Review. Current Osteoporosis Reports. August 2020. doi: https://doi.org/10.1007/s11914-020-00597-0. 

Wang X, et al. Alcoholism and Osteoimmunology. Current Medicinal Chemistry. 2021. doi: https://doi.org/10.2174/1567201816666190514101303. 

West, SL et al. Cardiovascular disease and bone loss — new research in identifying common disease pathophysiologies and predictors. AME Medicine Journal. March 2018. Doi: https://doi.org/10.21037/amj.2018.03.08. 

West Virginia Department of Health & Human Resources. Osteoporosis Risk Factors. https://dhhr.wv.gov/hpcd/FocusAreas/osteoporosis/Pages/Osteo-Risk-Factors.aspx.  

World Health Organization. Diabetes. https://www.who.int/health-topics/diabetes#tab=tab_1.  

Xu C, et al. Dietary Patterns and Progression of Knee Osteoarthritis: Data from the Osteoarthritis Initiative. The American Journal of Clinical Nutrition. January 2020. doi: https://doi.org/10.1093/ajcn/nqz333.