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PLoS One. 2019 Sep 16;14(9):e0222571. doi: 10.1371/journal.pone.0222571. eCollection 2019.

Prevalent vertebral fracture is dominantly associated with spinal microstructural deterioration rather than bone mineral density in patients with type 2 diabetes mellitus.

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Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Shimane, Japan.



An assessment of bone strength based on bone mineral density (BMD) underestimates the risk of fracture in patients with diabetes mellitus (T2DM). However, using the trabecular bone score (TBS) for estimating bone microarchitecture, previous studies showed that bone fragility is associated with deterioration of the microstructure concomitantly with decreased BMD. This study was conducted to clarify which of these skeletal-related factors had a more prominent relationship with bone fragility.


A retrospective cross-sectional study was performed at Shimane University Hospital. A total of 548 Japanese patients with T2DM [257 postmenopausal women and 291 men aged over 50 years] were included. TBS of the spine was computed from dual-energy X-ray absorptiometry images obtained from BMD measurements.


Vertebral fractures (VFs) were identified in 74 (28.8%) women and 115 (39.5%) men. A relationship between BMD and VFs was observed in the limited subgroup of women with a BMD T-score ≤-1.0. According to multivariate logistic regression analysis, low TBS was significantly correlated with prevalent VFs, independent of BMD in both genders, except for men with a BMD T-score > -1.0. The decision tree showed that the priority factor for determining VFs was TBS, not BMD.


Spinal microarchitecture represented by TBS was a more dominant skeletal factor for bone fragility than the decrease in bone mass, independent of BMD, in patients with T2DM. This observation suggests that loss of structural bone quality was crucial underlying pathogenesis for bone brittleness in these populations, regardless of gender. An integrated assessment of bone strength by BMD and TBS would help diagnose diabetic osteoporosis.

Conflict of interest statement

This work was supported by Grants-in-Aids for Scientific Research (C) Grant No. 25460900 (to MY) from Japan Society for the Promotion of Science (JSPS) ( and Asahi Kasei Pharma Corporation and Eli Lilly Japan K.K. The authors have declared that no competing interests exist including any employment and personal financial interests such as consultancy, patents, products in development, and marketed products. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

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