Diabetic Bone Disease: A Comprehensive Narrative Review of Pathophysiology, Diagnosis, and Evidence-Based Management

Background: Diabetic bone disease affects over 537 million people with diabetes worldwide, characterized by increased fracture risk despite paradoxically normal or elevated bone mineral density (BMD) in Type 2 diabetes. This narrative review synthesizes current evidence on pathophysiology, diagnostic approaches, and management strategies. Methods: We performed a comprehensive literature search of the PubMed, Embase, and Cochrane databases (2007–2025), prioritizing systematic reviews, meta-analyses, large-scale population studies, and clinical trials examining bone health in diabetes, including bone density, quality, fracture risk, imaging techniques, biomarkers, and therapeutic interventions. Results: Advanced glycation end products fundamentally alter bone metabolism through mechanisms distinct from traditional osteoporosis. Type 1 and Type 2 diabetes produce contrasting skeletal phenotypes requiring tailored management. Recent umbrella reviews of 71 meta-analyses demonstrated skeletal benefits of metformin and GLP-1 receptor agonists, while confirming thiazolidinedione risks. Trabecular bone score enhances fracture prediction when DXA appears normal. Large-scale studies revealed heterogeneous risk patterns, with specific subgroups showing substantially elevated fracture risk. Advanced imaging revealed distinct microarchitectural changes between diabetes types. Diabetic patients experienced doubled healing complications, necessitating specialized perioperative protocols. Conclusions: Diabetic bone disease represents a distinct clinical entity requiring enhanced diagnostic strategies beyond traditional densitometry, evidence-based treatment selection considering skeletal and metabolic effects, and specialized management protocols extending beyond conventional osteoporosis care.