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Clinical application
Diabetes and bone health
People with type 1 or type 2 diabetes face an elevated risk of fragility fractures, sometimes despite higher bone density than their peers. The reason is bone quality, and TBS® can help reveal it.
The diabetes paradox
Individuals with diabetes face an elevated risk of bone fragility and fractures, and this heightened risk can exist even when they have higher bone mineral density (BMD) than non-diabetic counterparts.
Normally, higher BMD should mean stronger bones. In diabetes, fracture risk stays high even when BMD is non-osteoporotic, pointing to compromised bone quality. Deteriorated bone microarchitecture and increased cortical porosity are common, linked in part to the accumulation of advanced glycation end products (AGEs) in bone.
Those with poorly controlled blood sugar are at even greater risk.
44,545
An ESCEO-IOF expert-group review encompassing a cohort of 44,543 individuals found TBS® offers better fracture-risk prediction in diabetes independent of BMD.1
When BMD or FRAX® is measured with TBS®, fracture-risk assessment becomes more accurate, reinforcing the need for a comprehensive, quality-aware approach in diabetic patients.
Assessment and management
Management addresses both the underlying metabolic condition and bone health. General recommendations include:
Screening & assessment
- DXA (BMD and TBS®) for postmenopausal women and men aged 50+ with diabetes, especially with additional fracture risk factors
- Use FRAX® to estimate 10-year risk — but with caution, as it may underestimate risk in type 2 diabetes
- Adjust BMD and/or FRAX® for TBS® to fine-tune the assessment for bone microarchitecture
Lifestyle & optimal diabetes control
- Calcium- and vitamin-D-rich diet, weight-bearing and balance exercises, limit alcohol, avoid smoking, and falls-prevention education
- Maintain good glycaemic control to reduce AGE accumulation in bone tissue
Pharmacological & monitoring
- Select anti-osteoporosis medication tailored to individual risk and severity
- Watch antidiabetic medications known to affect bone (e.g. thiazolidinediones), which may increase fracture risk
- Periodically reassess BMD and TBS® and adjust the plan
TBS in secondary osteoporsis
Cancer
Diabetes
HIV
Endocrine disorders
Chronic kidney disease, coming soon
Glucocorticoid-induced, coming soon
This content is for educational purposes for healthcare professionals and does not constitute medical advice or clinical guidance. It is not a substitute for the independent judgement of a qualified physician or specialist. Diagnostic and treatment decisions must be individualised to each patient, based on their complete clinical picture, locally applicable guidelines, and the most current evidence, which are determinations only a licensed healthcare provider is positioned to make.
References (1)
1. Shevroja, E., Reginster, J.-Y., Lamy, O., Al-Daghri, N., Chandran, M., Demoux-Baiada, A.-L., Kohlmeier, L., Lecart, M.-P., Messina, D., Camargos, B.M., Payer, J., Tuzun, S., Veronese, N., Cooper, C., McCloskey, E.V. and Harvey, N.C. (2023). Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging. Osteoporosis International, [online] 34(9), pp.1501–1529. doi:10.1007/s00198-023-06817-4.