Diabetes-Induced Osteoporosis: Dual Energy X-Ray Absorptiometry Bone Quality Is Better than Bone Quantity

Diabetes mellitus (DM) and osteoporosis are among the most common non-communicable diseases worldwide. Beyond their considerable socio-economic burden, both conditions significantly impair quality of life and reduce life expectancy, representing major causes of disability. DM-induced osteoporosis has recently emerged as a notable and frequent complication. Patients with type 2 DM have a twofold increased risk of fragility fractures, while those with longstanding type 1 DM exhibit a fivefold higher risk of hip, vertebral, and non-vertebral fractures. Bone mineral density (BMD) assessed by Dual Energy X-ray Absorptiometry (DXA) often fails to predict fracture risk in this population, as bone mass tends to be normal, slightly reduced, or even elevated. However, DXA-derived indices can offer additional clinical value. The Trabecular Bone Score (TBS), which reflects bone microarchitecture, is frequently reduced in patients with DM and is associated with increased fracture risk, particularly in postmenopausal women. TBS is also linked to glycemic control and microvascular complications and can improve with bone-active medications, thus aiding follow-up assessments. Another useful DXA-based tool is the Bone Strain Index (BSI), which evaluates load resistance and has been shown to be degraded in diabetic patients, offering further predictive value for fractures. Additionally, Hip Structural Analysis (HSA) provides information on the mechanical integrity of the proximal femur, which may be compromised in DM. Based on the available evidence, this review aims to highlight the clinical utility of DXA-derived tools in DM-induced osteoporosis, emphasizing their ability to provide quantitative and qualitative information on bone health and to predict the risk of fragility fractures.