The Effect of Type 2 Diabetes on Bone Quality: A Systematic Review and Meta-Analysis of Cohort Studies

There is a significant knowledge gap and limited studies have been carried out to evaluate the effect of type 2 diabetes (T2D) on bone quality and skeletal fragility. Previous reviews have tended to focus primarily on bone mineral density (BMD) as a measure of bone quality. However, BMD does not fully reflect the risk of fracture, cannot distinguish between cortical and trabecular bone, and bone fragility in patients with T2D results not only from alterations in bone mineralisation, but also due to changes in bone microarchitecture. In this regard, assessment tools such as trabecular bone score (TBS) and trabecular microarchitectural parameters could be useful and practical tools for examining bone status in people with T2D.

This review aims to examine the effect of type 2 diabetes on bone quality based on a variety of assessment tools.

The PRISMA checklist and PICOS framework were relied on for this systematic review and meta-analysis. Two researchers conducted the searches from database inception until 24/02/25. Databases including Academic Search Premier, APA PsycArticles, APA PsycInfo, CINAHL Plus with Full Text, MEDLINE, and the Psychology & Behavioral Sciences Collection were searched for relevant articles. The reference lists of articles were also searched. The Review Manager 5.4.1 software was used to carry out the meta-analysis.

Ten studies were included in the systematic review, while nine studies were included in the meta-analysis. Based on the narrative synthesis and meta-analysis, four distinct themes were established: bone mineral density, TBS and trabecular microarchitectural parameters, fracture risk, and body mass index (BMI). The meta-analysis of the effect of T2D on BMD showed that T2D significantly (p < 0.05) increased lumbar spine, total hip, femoral neck, and narrow neck BMD compared with controls. The mean differences (MDs) for the respective parameters were 0.04 (95% CI, 0.03, 0.05, p < 0.0001); 0.05 (95% CI, 0.02, 0.08, p = 0.002); 0.07 (95% CI, 0.04, 0.10, p < 0.0001); and 0.03 (95% CI, 0.01, 0.05, p = 0.0005). While there was a significant reduction (p < 0.0001) in the patients with T2D with respect to volumetric BMD, involving two studies and 1037 participants, with an MD of -12.36 (95% CI,-18.15, -6.57, p < 0.0001), T2D did not appear to have a significant effect (p > 0.05) on total BMD and area BMD compared to controls. In relation to TBS and trabecular microarchitectural parameters, the effect of T2D was not significant (p > 0.05) compared with controls. Furthermore, T2D did not have a significant effect (p > 0.05) on the incidence of hip fracture and non-spine fracture compared to controls. Following meta-analysis, it was found that the T2D significantly (p < 0.05) increased BMI compared to controls with an MD of 0.94 (95% CI, 0.74, 1.14, p < 0.0001).

Type 2 diabetes significantly increased (p < 0.05) lumbar spine, total hip, femoral neck, narrow neck BMD, and body mass index compared with controls. However, type 2 diabetes did not appear to have a significant effect (p > 0.05) on TBS, trabecular microarchitectural parameters, and the incidence of hip and non-spine fracture.