Bone health for people living with diabetes

It’s common to hear about the relationship between diabetes and the eyes, kidneys and feet. But, did you know that diabetes can also affect your bone health?

People living with diabetes face a multitude of challenges in managing their condition and bone health shouldn’t be overlooked. Understanding the impact of poor bone health to people living with diabetes is crucial in achieving overall well-being and quality of life.

Bones plays an important role in your overall health, from being a protective shield to delicate body parts to providing structure and support. Bones need to be strong yet light enough to keep you moving. You depend on your bones for many aspects of your life, from the visible (walking and dressing) to the invisible (serving as storehouses for essential nutrients and minerals that the body needs).

Bone modelling and remodelling

Like all of your body parts, bones are active tissue, which means they are actively changing throughout your lifetime. When a child is born, they have few bones that assist in giving them shape (structure) and support, and as they grow the new bones are formed from the cartilage. Every milestone a child achieves results in stronger bones and muscles that enable them to grow in height and become stronger.

There are two bone-making processes involved in the development, growth and shaping of bones  as well as the continuous renewal of bone tissue throughout life.

Bone modelling

During childhood and adolescence, new bone tissue is formed and broken down at different sites throughout the body, allowing bones to grow in size and shape. The process is called bone modelling and continues until age 25 – 30 when the child reaches adulthood.

In some cases the process can be interrupted by health conditions such as Type 1 diabetes, which means people living with Type 1 diabetes might not have full bone maturity .

Bone remodelling

During adulthood, bone remodelling involves the removal and replacement of bone at the same sites to:

  • Replace old bone that can become brittle.
  • Repair small cracks or deformation.
  • Release calcium and phosphorus into the circulation when need arises (dietary inadequacy, pregnancy, lactation).

Figure 1 bone growth[1]

Diabetes and bone health

For people living with Type 1 diabetes, the main concern is bone fragility (ability of bones to break easily at low impact). According of The Lancet Journal of Diabetes and Endocrinology, bone fragility is a recognised complication of Type 1 diabetes. People with Type 1 diabetes have lower bone mineral density (BMD) and greater fracture risk than individuals without diabetes (more than five times for hip fracture and two times for non-vertebral fractures).

Bone fragility becomes a complication because when a person living with diabetes experience a fracture, to repair that fracture isn’t a straightforward process, as such they experience a delay which impacts the proper repair and healing of that fracture.

The research also shows that people with Type 2 diabetes who have complications such as diabetic eye disease or kidney disease are also at increased risk of fragility fractures despite having higher bone mineral density compared to people living with Type 1 diabetes.

Another complication of diabetes is nerve damage which results in impaired movement, increasing the risk of falls. Low blood glucose reactions may also contribute to falls and fractures.

The duration of diabetes also plays a role as those living with the condition for more than five years tend to be at a higher risk for fractures and poor fracture healing.

Other factors of poor bone health

Other factors that can increase the risk of falls and poor bone health that lead to fractures are low levels of calcium and vitamin D. The body parts as well as other substances within the body such as minerals and nutrients don’t work in isolation but work together, which is the case with calcium and vitamin D. They work together to build your bones. People living with diabetes tend to have low vitamin D levels. Vitamin D helps the body to absorb calcium, which the body needs to maintain strong bones.

Hormone interference

There are also important hormones that affect the quality of your bones. As a person living with diabetes and having low levels of the following hormones increases your risks of bone fractures.

  • Low oestrogen is known for causing bone loss. If you’re a woman in menopause, had a hysterectomy with ovaries removed, or  a younger woman with irregular menstruation or menstruation that has stopped for many months even years, you’re at risk of osteoporosis.
  • Low testosterone can also affect bone health.
  • Vitamin D is a true hormone that is made on your skin when exposed to sunlight. Most spend times indoors and don’t receive enough sunlight to activate this essential element the body needs. As you get older, the amount of vitamin D that your skin produces gets diminished.
  • Thyroid balance is important not only for your weight and energy level, but also for your bones. An overactive thyroid or taking too much thyroid hormone to replace an underactive thyroid can make bones brittle within a few months.
  • Extra parathyroid hormone made by an enlarged parathyroid gland in your neck is a common cause of fragile bones and osteoporosis.
  • High cortisol, a stress hormone made in your adrenals, may present a risk of osteoporosis.


Osteoporosis (loss of bone mass) is a silent condition. This is why many people may not know they’re at risk or think about prevention until they have a fracture in an unexpected way.

Osteoporosis causes your bones to become weak and more prone to a fracture as you get older. The hip, spine and wrist are most susceptible, but a fracture may occur in any bone.

It’s normal for women to start experiencing a decrease in bone density when they enter menopause. This happens due to hormonal changes and is generally a slow process. Breaking a bone after falling while in a standing position could be a sign of osteoporosis. Any fracture should prompt a discussion of bone health with your doctor.

Osteoporosis is diagnosed with a bone density test, a quick and painless type of X-ray, that provides information about bone strength and the risk of a future fracture. Many people are surprised to learn they have osteoporosis because they have no symptoms.

Unfortunately, osteoporosis can have devastating consequences. Falling may lead to a life-altering fracture and permanent disability.

Earlier screening is recommended for women with certain risk factors, such as a family history of fractures or the use of certain medications (steroids). Those who consumed very little calcium in younger years, had an eating disorder, smoke or consume excessive amounts of alcohol may also be vulnerable to accelerated bone loss. Women who are underweight are also at increased risk.

Treatment for osteoporosis

Medications used to treat and prevent osteoporosis should be tailored for each individual patient.

Most people think of calcium and vitamin D when it comes to bones. However, there are so many more nutrients that are essential for bones, including vitamin B12, phosphorus, magnesium, and vitamin K, to name a few.

It’s preferable to get your calcium from food sources. Though, if supplements are taken, two forms are available: calcium carbonate is absorbed most efficiently when taken with food while calcium citrate is absorbed equally well with or without food.

It’s recommended that patients divide their dose for optimal absorption, taking no more 500mg at one time. A calcium supplement can interact with various prescription medications, so you should talk to your doctor about the best way to take it.

Diabetes and the risk for osteoporosis

People living with diabetes risk losing bone mass at a more rapid rate than average. This is due to complications such as muscle weakness, vision issues, low blood glucose, neuropathy in the feet, and certain diabetic medications that causes bone loss. The factor that increases the risk of osteoporosis the most is sedentary lifestyle.

Protecting bone health

  • Being physically active helps keep blood glucose levelled and is important for bone health. Weight-bearing exercises (walking, jogging and stair climbing) can prevent bone loss and build muscle strength to prevent falls. Maintaining a healthy weight can help preserve bone mass, even as you age and living with diabetes.
  • Eating well-balanced nutritious meals. Avoid refined carbohydrates (white bread and sweetened drinks) that cause blood glucose levels to spike. Limit caffeine (coffee and energy drinks) as they may affect calcium absorption.
  • Having good diabetes control to prevent complications associated with falling, such as nerve damage, vision loss, circulatory problems, and hypoglycaemia (low blood glucose).
  • Quitting all tobacco products. Smoking reduces blood supply to the bones and other organs, increasing the risk of diabetes complications.
  • Limiting, if not completely avoiding, alcohol. Alcohol affects all parts of the body, including the bones, and may cause changes in blood glucose levels.

People with diabetes should have a bone density test to monitor bone mineral density every two years. Routine bone density testing isn’t recommended for men younger than 70 unless they have other risk factors. Since women have a higher risk of osteoporosis, it’s recommended that all women above 50 years of age and post-menopausal women younger than 65 years of age with risk factors get a bone density test.  

Motselisi R Mosiana is a radiographer and the founder of Qsight which offers preventative and wellness care, corrective exercise, health coaching, clinical bone density and whole-body vibration screening.


Motselisi R Mosiana is a radiographer and the founder of InsureSPR Health which offers preventative and wellness care, corrective exercise, health coaching, clinical bone density and whole-body vibration screening.

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