In Chinese patients with type 2 diabetes (T2D), abdominal adiposity and its increases over time are independently associated with higher fracture risk. For general adiposity, the associations are fracture site–specific, with increased risks observed for both weight loss and weight gain.
These findings, from a longitudinal, population-based cohort study conducted by researchers from the Chinese University of Hong Kong, highlight the importance of considering both body fat distribution and longitudinal changes in adiposity when assessing fracture risk in T2D patients. [Diabetes Care 2026;49:1246-1257]
The study included 436,929 individuals with T2D (mean age, 61.9 years; median diabetes duration, 1 year; male, 53.1 percent) enrolled in the Hong Kong Hospital Authority’s Risk Assessment and Management Programme for Diabetes Mellitus (RAMP-DM) between August 2001 and February 2022. The participants were followed for incident fractures until June 2024.
General adiposity: Site-specific associations
Over a median follow-up of 8.3 years, any-site, major osteoporotic, and hip fractures occurred in 6.8, 4.4 and 2.5 percent of participants, respectively, corresponding to crude incidence rates of 7.75, 5.01 and 2.85 per 1,000 person-years. Overweight (BMI 23–24.9 kg/m2) and obese (BMI ≥25 kg/m2) participants had lower risks of these fractures, while underweight (BMI <18.5 kg/m2) participants had 30–77 percent higher risks, compared with those of normal weight.
Class II obesity (BMI ≥30 kg/m2) was associated with 21–36 percent higher risks of upper leg, ankle, rib, and humerus fractures.
Fracture risk increases with weight loss & weight gain
“Both weight loss and weight gain were associated with higher fracture risk, with the lowest risk observed in individuals with stable weight,” the researchers reported.
This U-shaped association between longitudinal weight changes and fracture risk was demonstrated in restricted cubic splines (RCS) analyses involving 247,540 participants with repeated adiposity measurements at 2 years.
The risk of any-site, major osteoporotic, hip, and humerus fractures was lowest at weight change in the range of -1.5 to +2.3 percent (poverall<0.01; pnonlinearity<0.01).
Compared with individuals with stable weight, those with 5–9.9 percent weight loss had 11–16 percent higher risks of any-site, major osteoporotic, and hip fractures, while those with ≥10 percent weight loss had 44–46 percent higher risks. Individuals with ≥10 percent weight gain had 13–83 percent higher risks of any-site, lower leg, humerus, and elbow fractures, while individuals with 5–9.9 percent weight loss had similar fracture risks as those with stable weight.
Abdominal obesity & its increases up fracture risk
“Abdominal adiposity and its increases were independently associated with higher fracture risk,” the researchers highlighted.
Waist circumference (WC) residuals from BMI were used to evaluate associations between abdominal adiposity and fracture risk independent of overall adiposity.
Compared with <5 percent change in WC, WC increase of ≥10 percent was associated with 14–54 percent higher risks of any-site, major osteoporotic, hip, rib, humerus, and elbow fractures. In contrast, WC decrease of ≥10 percent was associated with 24–29 percent lower risks of pelvis and wrist fractures in women.
“RCS analyses showed that increases in WC were associated with higher risks of hip and rib fractures [poverall<0.01], with steeper increases at greater gains [p nonlinearity<0.01], whereas the positive associations with humerus and elbow fractures were linear [poverall<0.001; pnonlinearity>0.05],” the researchers reported.