Integrating Radiology and Metabolic Risk: DEXA-Based Characterization of Bone Health in Type 2 Diabetes

<b>Background/Objectives</b>: Type 2 diabetes mellitus (T2DM) is increasingly recognized as a contributor to skeletal fragility despite patients often having a normal or even elevated bone mineral density (BMD), a phenomenon described as the "T2DM bone paradox." This study aimed to use DEXA screening to explore how metabolic and demographic factors, particularly body mass index (BMI), age, sex, and glycated hemoglobin (HbA1c), influence Bone Mineral Density (BMD) among Saudi adults, a population where diabetes and obesity are highly prevalent. <b>Methods</b>: A retrospective cross-sectional study was conducted among 89 adults (mean age 61.1 years; 82% female) who underwent dual-energy X-ray absorptiometry (DEXA) at King Fahad Specialist Hospital in Tabuk, Saudi Arabia. Bone mineral density was evaluated at the lumbar spine, femoral neck, and total hip. Correlation and multiple regression analyses were conducted to assess how age, sex, body mass index (BMI), and glycated hemoglobin (HbA1c) were related to BMD T-scores. <b>Results</b>: The prevalence of osteopenia and osteoporosis was 43.8% and 23.6%, respectively, with women and older adults showing the highest rates of low bone mass. Participants had a mean age of 61.1 ± 12.1 years, average BMI of 32 kg/m², and mean HbA1c of 6.6 ± 1.8%. Females showed slightly lower T-scores at all skeletal sites compared with males (lumbar spine -1.81 vs. -1.55; femoral neck -1.15 vs. -0.76; total hip -0.62 vs. -0.12), indicating greater bone loss in women. BMI was consistently and positively associated with BMD across all skeletal sites (<i>p</i> < 0.05), whereas age and female sex were negative predictors at the femoral neck and hip. HbA1c showed a paradoxical positive relationship with BMD at weight-bearing sites, reflecting the complexity of metabolic effects on bone quality. The models explained up to 28% of the variance in BMD. <b>Conclusions</b>: Individuals with higher level BMI tended to have better bone mass, while older age and female sex were related to decreased BMD. The positive association between HbA1c and BMD supports the concept of the "diabetic bone paradox" and emphasizes the value of combining the evaluation of both metabolic and skeletal factors when assessing fracture risk in Middle Eastern populations.