Available online 22 October 2025, 101640

Author links open overlay panel, AbstractObjective

To investigate the relationship between body mass index (BMI) and areal bone mineral density (BMD) as well as trabecular bone score (TBS) in adults with type 2 diabetes mellitus (T2DM) and to determine whether age or sex modifies these relationships.

Methods

We retrospectively identified 762 community-dwelling adults aged ≥ 50 years (257 with T2DM and 505 non-diabetic controls) who underwent dual-energy X-ray absorptiometry at our centre between August 2023 and May 2024. Lumbar-spine and femoral-neck BMD as well as TBS were extracted. Associations were evaluated with Spearman’s ρ and multiple linear regression, adjusting for age and sex.

Results

In men, BMI, BMD and TBS did not differ between diabetic and non-diabetic participants in any age stratum (all P > 0.05). Women aged 50–60 y with T2DM exhibited higher LS-BMD but lower TBS than non-diabetic peers (both P < 0.05), indicating early dissociation between density and micro-architecture. Correlation analysis shows a positive association between BMI and LS-BMD (ρ=0.286, P= 0.002). Multivariate linear regression confirmed that BMI was an independent positive predictor of LS-BMD (β = 0.276, P < 0.001) and an independent negative predictor of TBS (β = −0.069, P = 0.043).

Conclusion

In T2DM, higher BMI is independently associated with greater BMD but poorer trabecular micro-architecture. This paradox is most evident in post-menopausal women, underscoring TBS as an early warning tool when BMD remains normal.

Introduction

The escalating global burden of type 2 diabetes mellitus (T2DM) is accompanied by a paradoxical increase in fracture risk that persists despite normal or even elevated bone mineral density (BMD).1 Visceral adiposity-driven chronic inflammation and insulin resistance impair trabecular micro-architecture, a pathology undetectable by areal BMD.2 Trabecular Bone Score (TBS)—a gray-level texture index derived from lumbar spine DXA—consistently identifies deteriorated micro-architecture in individuals with T2DM, independent of BMD. Crucially, TBS measurements remain unaffected by Body Mass Index (BMI)3 offering a novel perspective to explain this apparent paradox. However, Quantitative data on age- and sex-specific relationships between BMI, BMD and TBS in T2DM remain scarce. Using a large retrospective cohort, we dissected the triangular associations among BMI, BMD and TBS in adults with T2DM and tested whether age or sex modifies these relationships. It aims to construct a more precise bone quality assessment model, providing theoretical foundations for the early identification and personalised intervention of diabetic osteoporosis.

Section snippetsParticipants

We retrospectively enrolled 762 community-dwelling adults (men ≥ 50 y; post-menopausal women) who underwent dual-energy X-ray absorptiometry (DXA) at the Department of Medical Imaging, Jinjiang Hospital, between August 2023 and May 2024. Of these, 257 had type 2 diabetes mellitus and 505 served as non-diabetic controls. Mean age was 62.3 ± 10.7 y (range 50–97); 196 participants were men and 566 were women.

Inclusion criteria: Type 2 diabetes was defined according to the 2020 Chinese guideline4:

Results

Of 762 eligible participants, 257 had T2DM (59 men, 198 women) and 505 served as non-diabetic controls (137 men, 368 women). Mean age did not differ between the two groups (P > 0.05).

In men, BMI, FN-BMD and TBS were comparable between diabetic and non-diabetic participants in every age stratum (all P > 0.05).

Women aged 50–60 y with T2DM exhibited higher LS-BMD (median −1.7 vs −2.2, P = 0.042) but lower TBS (1.30 ± 0.08 vs 1.34 ± 0.09, P = 0.029) than non-diabetic peers, denoting early

Discussion

The clinical paradox of "high bone mineral density with high fracture risk" in T2DM-induced skeletal fragility remains unresolved.6 Our study systematically investigates the complex interplay among BMI, BMD, and TBS in patients with T2DM through multivariate regression and Spearman correlation analyses, with particular emphasis on the moderating effects of age and gender. Our core findings reveal that, after adjusting for confounding factors, BMI exerts independent and oppositely directed

Conclusion

In summary, this study rigorously demonstrated through multivariate analysis that BMI exerts a dual effect on skeletal health in T2DM patients: it acts as a protective factor for bone mineral density while simultaneously serving as a potential risk factor for bone microarchitecture. This complex relationship is significantly modulated by gender and age, rendering middle-aged women the cohort most prominent in skeletal risk. Consequently, clinical skeletal health assessments must transcend the

References (23)V.V. Shanbhogue et al.Type 2 diabetes and the skeleton: new insights into sweet bones[J]. The Lancet

Diabetes & Endocrinology

(2016)

N. Rianon et al.Trabecular Bone Score Is a Valuable Addition to Bone Mineral Density for Bone Quality Assessment in Older Mexican American Women With Type 2 Diabetes[J]

Journal of Clinical Densitometry: The Official Journal of the International Society for Clinical Densitometry

(2018)

Q. Gao et al.Advanced glycation end products mediate biomineralization disorder in diabetic bone disease[J]

Cell Reports. Medicine

(2024)

B.T. Ge et al.Research progress on MLR, WLR and OSTA indices and bone mineral density in patients with type 2 diabetes mellitus [J/OL]

Clinical Personalized Medicine

(2024)

L.I.U. Ching-TiVisceral Adipose Tissue Is Associated With Bone Microarchitecture in the Framingham Osteoporosis Study

Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research

(2025)

R.A.N. BingyuApplication and prospect of trabecular bone score in differentiated thyroid cancer patients receiving thyrotropin suppression therapy

Frontiers in endocrinology

(2025)

Chinese guideline for the prevention and treatment of type 2 diabetes mellitus (2020 edition) [J/OL]

Chinese Journal of Diabetes

(2025)

Guideline for the diagnosis and treatment of primary osteoporosis (2022)[J/OL]

Chinese General Practice

(2023)

N. Napoli et al.Mechanisms of diabetes mellitus-induced bone fragility[J]

Nature Reviews. Endocrinology

(2017)

B. Xu et al.Contradictory links between lipid levels and bone health: atherogenic index of plasma and bone microarchitecture[J]

Journal of Orthopaedic Surgery and Research

(2025)

Y. Ouyang et al.Saturation Effect of Body Mass Index on Bone Mineral Density in Adolescents of Different Ages: A Population-Based Study[J/OL]

Frontiers in Endocrinology

(2022)

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© 2025 The International Society for Clinical Densitometry. Published by Elsevier Inc.