Bone microstructure and TBS in diabetes: what have we learned? A narrative review

S Ferrari¹, K E Akesson^{2

3}, N Al-Daghri⁴, E Biver¹, M Chandran⁵, T Chevalley¹, R G Josse⁶, D L Kendler⁷, N E Lane⁸, P Makras⁹, C Meier¹⁰, Ambrish Mithal¹¹, A Suzuki¹², S Vasikaran¹³, D D Pierroz¹⁴, W D Leslie¹⁵; International Osteoporosis Foundation Committee of Scientific Advisors Working Group on Bone and Diabetes

Collaborators, Affiliations

Collaborators

International Osteoporosis Foundation Committee of Scientific Advisors Working Group on Bone and Diabetes:
B Abrahamsen, K Akesson, N Al-Daghri, E Biver, M Chakhtoura, M Chandran, T Chevalley, C Cooper, R Eastell, S Ferrari, C Glüer, G El Hajj Fuleihan, R Josse, D Kendler, N Lane, W Leslie, P Makras, A Mithal, C Meier, N Napoli, A Suzuki, S Vasikaran

Affiliations

¹ Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
² Orthopedics, Department of Clinical Sciences, Lund University, Malmö, Sweden.
³ Department of Orthopedics, Skåne University Hospital, Malmö, Sweden.
⁴ Department of Biochemistry, College of Science, King Saud University, Riyadh, Saudi Arabia.
⁵ Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, DUKE NUS Medical School, Singapore, Singapore.
⁶ Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁷ Department of Medicine (Endocrinology), University of British Columbia, Vancouver, BC, Canada.
⁸ Division of Rheumatology, Department of Medicine, U.C. Davis Health, Sacramento, CA, USA.
⁹ Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece.
¹⁰ Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland.
¹¹ Institute of Endocrinology and Diabetes, Max Healthcare, Delhi, India.
¹² Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Aichi, Japan.
¹³ Department of Clinical Biochemistry, PathWest-Fiona Stanley Hospital, Perth, Australia.
¹⁴ International Osteoporosis Foundation (IOF), Nyon, Switzerland.
¹⁵ Department of Internal Medicine, University of Manitoba, C5121 - 409 Tache Avenue, Winnipeg, MB, R2H 2 A6, Canada. bleslie@sbgh.mb.ca.

PMID: 40353870
DOI: 10.1007/s00198-025-07495-0

Review

Bone microstructure and TBS in diabetes: what have we learned? A narrative review

S Ferrari et al. Osteoporos Int. 2025 Jul.

. 2025 Jul;36(7):1115-1128.

doi: 10.1007/s00198-025-07495-0. Epub 2025 May 12.

Authors

Collaborators

International Osteoporosis Foundation Committee of Scientific Advisors Working Group on Bone and Diabetes:
B Abrahamsen, K Akesson, N Al-Daghri, E Biver, M Chakhtoura, M Chandran, T Chevalley, C Cooper, R Eastell, S Ferrari, C Glüer, G El Hajj Fuleihan, R Josse, D Kendler, N Lane, W Leslie, P Makras, A Mithal, C Meier, N Napoli, A Suzuki, S Vasikaran

Affiliations

¹ Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
² Orthopedics, Department of Clinical Sciences, Lund University, Malmö, Sweden.
³ Department of Orthopedics, Skåne University Hospital, Malmö, Sweden.
⁴ Department of Biochemistry, College of Science, King Saud University, Riyadh, Saudi Arabia.
⁵ Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, DUKE NUS Medical School, Singapore, Singapore.
⁶ Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁷ Department of Medicine (Endocrinology), University of British Columbia, Vancouver, BC, Canada.
⁸ Division of Rheumatology, Department of Medicine, U.C. Davis Health, Sacramento, CA, USA.
⁹ Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece.
¹⁰ Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland.
¹¹ Institute of Endocrinology and Diabetes, Max Healthcare, Delhi, India.
¹² Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Aichi, Japan.
¹³ Department of Clinical Biochemistry, PathWest-Fiona Stanley Hospital, Perth, Australia.
¹⁴ International Osteoporosis Foundation (IOF), Nyon, Switzerland.
¹⁵ Department of Internal Medicine, University of Manitoba, C5121 - 409 Tache Avenue, Winnipeg, MB, R2H 2 A6, Canada. bleslie@sbgh.mb.ca.

PMID: 40353870
DOI: 10.1007/s00198-025-07495-0

Abstract

Diabetes is associated with an increased risk of fracture. Areal bone mineral density (aBMD), the most reliable indicator of fracture risk in healthy adults, is low in patients with type 1 diabetes mellitus but normal or high in patients with type 2 diabetes mellitus. Most trabecular and cortical parameters measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) are lower in type 1 diabetes and higher in type 2 diabetes, in parallel with aBMD. In contrast, lumbar spine trabecular bone score (TBS) has been reported to be lower in women with both type 1 and type 2 diabetes. The discordance between improved bone microstructure and degraded TBS reflects the effect of central obesity (currently the subject of a revision to the TBS algorithm). Meanwhile, evidence supports use of TBS in conjunction with aBMD and/or FRAX for improved fracture prediction in patients with type T2D. This position paper, on behalf of the Bone and Diabetes Working Group of the International Osteoporosis Foundation, summarizes alterations in bone microarchitecture measured by HR-pQCT in diabetes. It also addresses the technical and clinical considerations of the trabecular bone score, particularly discussing the significance of this measurement in individuals with diabetes and the influence of abdominal fat.

Keywords: Bone Microstructure; Diabetes; HRpQCT; Trabecular Bone Score (TBS).

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Conflict of interest statement

Declarations. Conflict of interest: This narrative article contains no original data, and thus issues of ethics, informed consent and patient confidentiality do not apply. Conflict of interest: S Ferrari, KE Akesson, N Al-Daghri, E Biver, M Chandran, T Chevalley, RG Josse, DL Kendler, NE Lane, P Makras, C Meier, A Mithal, A Suzuki, S Vasikaran, DD Pierroz, WD Leslie declare no competing interest in relation to this work.

References

1. Hough FS, Pierroz DD, Cooper C, Ferrari SL, Bone IC, Diabetes WG (2016) Mechanisms in endocrinology: Mechanisms and evaluation of bone fragility in type 1 diabetes mellitus. Eur J Endocrinol 174(4):R127–R138 - PubMed - DOI
1. Napoli N, Chandran M, Pierroz DD, Abrahamsen B, Schwartz AV, Ferrari SL et al (2016) Mechanisms of diabetes mellitus-induced bone fragility. Nat Rev Endocrinol 13(4):208–219 - PubMed - DOI
1. Forsen L, Meyer HE, Midthjell K, Edna TH (1999) Diabetes mellitus and the incidence of hip fracture: results from the Nord-Trondelag Health Survey. Diabetologia 42(8):920–925 - PubMed - DOI
1. Bonds DE, Larson JC, Schwartz AV, Strotmeyer ES, Robbins J, Rodriguez BL et al (2006) Risk of fracture in women with type 2 diabetes: the women’s health initiative observational study. J Clin Endocrinol Metab 91(9):3404–3410 - PubMed - DOI
1. Giangregorio LM, Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E et al (2012) FRAX underestimates fracture risk in patients with diabetes. J Bone Miner Res 27(2):301–308 - PubMed - DOI

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Bone microstructure and TBS in diabetes: what have we learned? A narrative review

Collaborators

Affiliations

Bone microstructure and TBS in diabetes: what have we learned? A narrative review

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical