Question 4: Diet and exercise and general lifestyle interventions are important in patients with concomitant type 2 diabetes and osteoporosis. What type of nutrition therapy should clinicians be recommending in these patients?

Answer 4: Unfortunately, there are no data that a specific nutrition therapy would be beneficial for bone health in patients with diabetes. However, adequate calcium and vitamin D intake, according to the Institute of Medicine recommendations, seems prudent.3 Although significant weight loss is important for treating diabetes, it might be detrimental to bone health. Weight-bearing exercise can attenuate the bone loss associated with weight loss and therefore should be encouraged in patients with diabetes who are following a weight-loss program. Finally, adequate protein intake is important for musculoskeletal health and is a basic component of a healthy diet in patients with diabetes.3

Question 5: Are clinicians doing enough to counsel patients who have diabetes and osteoporosis on nutrition — not just for the sake of their diabetes but also for their osteoporosis?

Answer 5: Nutrition is an important component in the management of diabetes, and I am sure all clinicians address this issue with their patients. The lack of evidence for skeletal benefits from a particular nutrition intervention probably prevents clinicians from providing any specific nutritional guidance for bone health. And even though clinicians will probably ensure adequate calcium and vitamin D intake in patients with diabetes with established osteoporosis, this might not be the case in patients who have not had a fracture yet, as we generally tend to underestimate the fracture risk in patients with diabetes.3

Question 6: While some diabetes medications may affect bone health, osteoporosis medications do not seem to have negative effects on diabetes or blood sugar. Is this true, and should more research be conducted on the effects of osteoporosis medications on glucose metabolism?

Answer 6: There are several studies showing that bisphosphonates are safe in terms of effects on glycemic control and the risk for developing diabetes. Data show either neutral or even beneficial effects, so clinicians should not be concerned that bisphosphonates might negatively affect their patients’ diabetes.1 There is less evidence for the other osteoporosis medications, but results so far are rather reassuring. Newer, recently US Food and Drug Administration (FDA) approved osteoporosis medications and medications currently awaiting approval definitely require more research.

Another thing that needs to be taken into consideration is the potential negative effects of osteoporosis medications on cardiovascular disease (CVD) risk, as most patients with diabetes are already at a high risk for CVD. While most osteoporosis medications are safe in terms of CVD risk, some may increase this risk. Strontium ranelate, which is licensed in Europe for osteoporosis, was recently withdrawn from the market by the manufacturer due to cardiac safety concerns. In addition, the development of odanacatib, a cathepsin K inhibitor, was withheld after a phase 3 trial showed an increased risk for stroke.1


  1. Paschou SA, Dede AD, Anagnostis PG, Vryonidou A, Morganstein D, Goulis DG. Type 2 diabetes and osteoporosis: a guide to optimal management. [published online: June 21, 2017] J Clin Endocrino Metab. doi:10.1210/jc.2017-00042
  2. Watts NB, Bilezikian JP, Usiskin K, et al. Effects of canagliflozin on fracture risk in patients with type 2 diabetes mellitus. J Clin Endocrinol Metab. 2016;101(1):157-166. doi:10.1210/jc.2015-3167
  3. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011