Diabetes progression and its association with fracture risk in type 2 diabetes

People with type 2 diabetes mellitus (T2DM) accumulate factors that weaken bone. In over two million adults, fracture risk rose stepwise as diabetes progressed, with the steepest increase for hip fractures. A simple progression score using routine clinical data may help flag patients who need earlier bone-protective care.

Patients with type 2 diabetes mellitus (T2DM) are often exposed to multiple factors contributing to bone fragility-such as poor glycemic control, long duration of exposure to hyperglycemia, and comorbidities. Because these factors often accumulate over time, we examined whether fracture risk increases with diabetes progression.

We analyzed data from 2,069,920 patients with T2DM from the Korean National Health Information Database who underwent health examinations in 2015-2016. Patients with a prior history of fractures or who died within one year were excluded. Diabetes progression was scored from 0 to 6 based on the number of oral glucose-lowering drugs, disease duration, insulin use, and presence of chronic kidney disease, cardiovascular disease (CVD), or diabetic retinopathy. Incident fractures were tracked until 2023 using ICD-10 codes.

Over a median follow-up of 6.4 years, 169,595 fractures occurred, including 69,723 vertebral and 23,581 hip fractures. Each component of diabetes progression was independently associated with fracture risk (hazard ratios [HRs] ranging from 1.14 to 1.40). Insulin use (HR, 1.40; 95% confidence interval [CI]: 1.38-1.42) and CVD (HR, 1.26; 95% CI: 1.24-1.28) conferred notably higher risks. Fracture risk increased progressively with higher progression scores (HRs for score 4: 1.60; 95% CI: 1.56-1.64; HRs for score 5: 1.87; 95% CI: 1.78-1.96). The magnitude of increase was more pronounced for hip fractures.

The risk of fractures increased incrementally in parallel with diabetes progression, most notably for hip fractures. Diabetes progression metrics may help identify patients at elevated fracture risk.