Diabetes increases fracture risk through mechanisms beyond bone mineral density (BMD), making standard tools prone to underestimation—especially in type 2 diabetes (T2DM). While osteoporosis is densitometrically evident in type 1 diabetes (T1DM), both T1DM and T2DM have higher rates of low-energy fractures (hip, vertebrae, humerus; plus forearm/foot in T2DM). Contributing factors include impaired bone microarchitecture, accumulation of AGEs, low osteocalcin/P1NP with higher sclerostin, microvascular disease, hypercalciuria, vitamin D deficiency, and fall risks (neuropathy, vision loss, hypoglycemia, sarcopenia). FRAX can underestimate risk in T2DM. Trabecular bone score (TBS) adds microarchitectural insight and improves risk prediction when combined with BMD. Screening guidance suggests earlier and repeated dual-energy X-ray absorptiometry in T1DM (starting ~5 years after diagnosis) and careful interpretation of “normal” or “high” BMD in T2DM, where fracture risk may still be elevated.

Management centers on optimal glycemic control, fall prevention, vitamin D/calcium repletion, weight-bearing/strength exercise, and addressing modifiable risks (smoking, alcohol). For diabetes therapies, metformin, DPP-4 inhibitors, sulfonylureas, and GLP-1 receptor agonists are neutral/beneficial for bone. Thiazolidinediones and canagliflozin are associated with higher fracture risk and should be avoided when possible. Clinicians should incorporate TBS (and consider FRAX-with-TBS adjustment), recognize that patients with T2DM fracture at higher BMD, and maintain high suspicion for “diabetic bone disease.”

Reference: Tomasiuk JM, Nowakowska-Płaza A, Wisłowska M, Głuszko P. Osteoporosis and diabetes - possible links and diagnostic difficulties. Reumatologia. 2023;61(4):294-304. doi: 10.5114/reum/170048.

Researchers of this randomized trial (IGNITE) tested whether using continuous glucose monitoring (CGM) versus finger-stick blood glucose monitoring (BGM) to guide diet and medication during a medically supervised ketogenic diet program (delivered via continuous remote care) would differentially improve glycemia in adults with type 2 diabetes. Participants (n=163; mean HbA1c 8.1%, diabetes duration ~10 years) were assigned to CGM (n=81) or BGM (n=82). Glycemia, medication, ketones, diet, and weight were assessed at baseline, 1 month, and 3 months, with care teams using the data to titrate therapy and reinforce dietary targets.

Both groups achieved large, clinically meaningful gains. Time in range rose from about 61% to 63% at baseline to about 85% to 89% at 3 months (P<0.001) with no between-arm difference (P=0.26). Additional CGM metrics improved by month 1 and were maintained to month 3. HbA1c fell by at least 1.5% in both arms; diabetes medications were de-intensified; total energy and carbohydrate intake decreased; and participants in both arms lost clinically significant weight (all P<0.001). Taken together, the results suggest that within a structured ketogenic program supported by continuous remote care, the choice of glucose monitoring modality may matter less than the intensity of dietary intervention and follow-up, though more CGM-guided nutrition trials are warranted.

Reference: Willis HJ, Asche SE, McKenzie AL, et al. Impact of Continuous Glucose Monitoring Versus Blood Glucose Monitoring to Support a Carbohydrate-Restricted Nutrition Intervention in People with Type 2 Diabetes. Diabetes Technol Ther. 2025 May;27(5):341-356. doi: 10.1089/dia.2024.0406.

Researchers of a randomized crossover trial in 24 adults with type 2 diabetes tested whether breaking up 8 hours of sitting with brief activity affects incretin hormones. Every 30 minutes, participants either remained seated (control) or did 3-minute bouts of light walking or simple resistance activities, with standardized breakfast and lunch and blood draws every 30 minutes. Both activity conditions significantly reduced postprandial glucose-dependent insulinotropic polypeptide (GIP) versus uninterrupted sitting, while GLP-1 was unchanged. Sex-stratified analyses suggested overall higher incretin levels in males and a somewhat greater GIP reduction in females, but only one meal-specific interaction reached significance.

The authors note that lower postprandial GIP has been linked to reduced cardiovascular risk and may partly explain the known benefits of interrupting sedentary time on glucose and insulin responses. Proposed mechanisms include altered gastric emptying, improved insulin sensitivity, and increased skeletal muscle glucose uptake. However, hormone-only measurements limit mechanistic inference. Strengths were the randomized crossover design and controlled setting. Limitations include the acute, small-sample nature and sparse early postprandial sampling. Overall, frequent light activity breaks lowered GIP (not GLP-1) in type 2 diabetes, warranting larger studies to confirm durability, mechanisms, and possible sex-specific effects.

Reference: Logan BK, Larsen R, Sacre JW, et al. Interrupting prolonged sitting reduces postprandial GIP but not GLP-1 responses in type 2 diabetes. Diabetes Obes Metab. 2025 Nov;27(11):6771-6774. doi: 10.1111/dom.70046.