This content originally appeared on diaTribe. Republished with permission.

By April Hopcroft

Key takeaways: 

People with type 1 and type 2 diabetes have an increased risk of developing osteoporosis and experiencing bone fractures.
Maintaining a healthy body weight and eating a nutritious diet are key to healthy bones – be sure to get enough calcium and vitamin D, in particular.
Other ways to reduce osteoporosis risk include engaging in regular strength training and receiving recommended screenings, and keeping up with blood sugar management.

Unless you’ve recently broken something, bone health may not be top of mind. But keeping bones healthy is critical, especially for people with diabetes, who may be at higher risk for osteoporosis.

Even if you’ve already been diagnosed with osteoporosis, it’s never too late to start building strong bones and prevent breaks. We spoke to Dr. Rasa Kazlauskaite, an endocrinologist with extensive experience in osteoporosis, to understand the connection between bone disease and diabetes.

What is osteoporosis?

Osteoporosis is a condition that causes bones to become weak and brittle. This increases the risk of bone fractures from even minor stresses, such as falling from a standing position or even from coughing, Kazlauskaite said.

Like your skin, bone is living tissue that is continually re-growing. Osteoporosis happens when old bone is lost faster than new bone can be created. Often, people with osteoporosis don’t notice any symptoms in the early stages – you can’t feel your bones getting smaller and thinner. In later stages, you may notice loss of height, stooped posture, or broken bones (commonly in the spine, hip, or wrist). Often the first sign of osteoporosis is a fractured bone.

“We hear all about heart attack prevention, but we don’t hear about fracture risk,” Kazlauskaite said.

While many can people heal quickly from a break without complications, bone fractures may require a long-term need for crutches, a wheelchair, or a walker – especially in older adults. Long periods of being immobile can lead to many different complications and infections, which may take longer to heal with diabetes.

Diabetes-related complications like neuropathy and vision problems can also increase the risk of fractures, Kazlauskaite said. For instance, peripheral neuropathy can reduce foot strength, which could lead to serious falls. Likewise, if you can’t see properly, you may be more likely to trip and fall.

Risk factors for osteoporosis

While diabetes doesn’t cause osteoporosis, it can raise the risk of developing it. Having diabetes (type 1 or type 2) also increases the risk of fractures. In type 1 diabetes, people tend to have low bone mineral density and may have impaired bone formation, both of which can contribute to osteoporosis.

Other risk factors include:

Aging: Bone growth slows as we age and bone loss happens faster, increasing the risk for bone disease.
Biological sex: Women generally are at higher risk for osteoporosis as they tend to have smaller, less dense bones than men.
Ethnicity: White and Asian women ages 50 and older have an increased risk of osteoporosis due to lower bone density.
Hormonal changes: Women who’ve gone through menopause are at higher risk of osteoporosis due to a drop in estrogen levels (low estrogen can reduce bone density. Low testosterone can also increase the risk since testosterone plays a role in keeping bones strong.
Low body weight: People who weigh less than 125 pounds have a greater risk of osteoporosis.
Other conditions: Kidney failure, liver disease, inflammatory bowel disease, arthritis, and eating disorders could contribute to the development of osteoporosis.
Medications: Some drugs impact calcium absorption and bone formation, potentially increasing the risk of osteoporosis. This includes diabetes medications like sulfonylureas, thiazolidinediones, and SGLT-2 inhibitors, as well as diuretics (water pills), which are used to manage kidney and cardiovascular disease.

Five ways to strengthen bones

Whether you have osteoporosis or are trying to prevent it, there are lots of steps you can take to maintain bone health long-term.

1. Maintain a healthy body weight

Weight management is an important aspect of osteoporosis prevention. Being underweight or living with obesity can increase the risk of thinning bones and fractures.

Generally, people with smaller frames have a greater risk of osteoporosis as they tend to have less bone mass. Their bones are also more likely to become fragile with age, Kazlauskaite said.

Meanwhile, obesity can increase the risk of fractures, especially at the tibia (shinbone), humerus (upper arm), and ankle. Weight loss – especially rapid weight loss through bariatric surgery – reduces bone mass, which can increase the risk of osteoporosis.

2. Practice strength training

While strength training (also called resistance training) is widely viewed as a way to build muscle, it can also help maintain healthy bones and reduce fracture risk.

Any sort of weight-bearing exercise – walking, running, dancing, or even pickleball – will put force on your bones and help strengthen them. Weight-bearing exercises help stimulate bones to renew themselves, Kazlauskaite explained.

A 2022 study found that resistance training increased bone mineral density in women who had gone through menopause. Strength exercises like weight lifting also improve posture and balance, which can help prevent falls. If you use free weights or weight machines, it’s a good idea to start small and build up slowly.

Be sure to wear proper shoes for any physical activity, Kazlauskaite said, as people with diabetes are at an especially high risk of fractures in the ankle and tibia. Diabetes-related foot complications such as Charcot foot may be related to fractures that have gone unnoticed. If you’re unable to exercise due to injuries, Kazlauskaite recommended programs such as Osteostrong.

3. Eat a calcium-rich diet

Remember being told as a kid to finish your milk because it builds strong bones? That’s because milk contains calcium, a mineral that helps form bones and keep them strong. Good sources of calcium include milk, cheese, yogurt, seeds, beans and lentils, leafy greens, and fish.

Kazlauskaite recommended tracking your calcium intake through an app like My Fitness Pal or MyNetDiary. Ideally, you should consume at least 1,000 mg of calcium per day, she said. People who have gone through menopause may have higher calcium needs (around 1,200 mg per day).

If you’re not able to get enough calcium through your diet, supplements can help. Most people start with calcium citrate, but you may want to consider calcium phosphate if you experience side effects from calcium citrate, Kazlauskaite advised.

4. Get enough vitamin D

Vitamin D is also important for strong bones since it helps your body absorb calcium. Good sources of vitamin D include egg yolks, mushrooms, and certain fish like salmon, tuna, and sardines. Several foods are fortified with vitamin D, including milk, orange juice, cereal, and oatmeal.

If you are taking vitamin D supplements, Kazlauskaite recommends getting your levels checked so you know where things stand. For osteoporosis prevention, vitamin D levels should be at least 30 ng/mL. Over-the-counter vitamin D supplements are available at most drugstores and grocery stores.

If for any reason your healthcare provider isn’t able to offer vitamin D testing, Kazlauskaite suggested the website walkinlab.com, which allows you to sign up for low-cost testing on your own.

5. Get screened for osteoporosis

For people with diabetes, bone mineral density scans are usually recommended for women when they enter menopause and for men around age 50, according to the American Diabetes Association.

Due to the higher chance of fractures, people with diabetes need to be tested for bone fracture risk, Kazlauskaite said. This includes the FRAX risk calculator, testing for falls, and evaluation with laboratory tests and a bone density (DXA) scan.

For people with type 1 diabetes, DXA scans are recommended at the time of diagnosis and every 2-5 years. The bone density testing must include trabecular bone score (TBS), Kazlauskaite noted.

Treatment for osteoporosis

If you’ve been diagnosed with osteoporosis, treatment may involve medications and lifestyle changes. Common medications to treat osteoporosis are bisphosphonates like alendronate. Another treatment is denosumab, an injection given every six months. Interestingly, new research shows alendronate and denosumab may reduce the risk of developing type 2 diabetes.

Hormone therapy may be recommended for women who’ve gone through menopause or people with low testosterone. As with osteoporosis prevention, an important part of treatment is keeping bones strong and healthy – this includes getting regular exercise, eating nutritiously, and maintaining a healthy weight.

The bottom line

It’s never too early to start thinking about osteoporosis and taking steps to strengthen your bones. Managing your diabetes through healthy lifestyle changes and keeping blood glucose levels in target range can go a long way toward reducing your risk of complications, including osteoporosis.

Learn more about diabetes:

The Forgotten Complications – What You Should Know
Diabetes, Aging, and Muscle Loss
High-Intensity Interval Training for Diabetes