Diabetes Metab J.  2023 Mar;47(2):242-254. 10.4093/dmj.2022.0001.

Association of Body Mass Index and Fracture Risk Varied by Affected Bones in Patients with Diabetes: A Nationwide Cohort Study

  • 1Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
  • 2Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
  • 3Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
  • 4Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
  • 5Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea


Body mass index (BMI) is a risk factor for the type 2 diabetes (T2DM), and T2DM accompanies various complications, such as fractures. We investigated the effects of BMI and T2DM on fracture risk and analyzed whether the association varied with fracture locations.
This study is a nationwide population-based cohort study that included all people with T2DM (n=2,746,078) who received the National Screening Program during 2009–2012. According to the anatomical location of the fracture, the incidence rate and hazard ratio (HR) were analyzed by dividing it into four categories: vertebra, hip, limbs, and total fracture.
The total fracture had higher HR in the underweight group (HR, 1.268; 95% CI, 1.228 to 1.309) and lower HR in the obese group (HR, 0.891; 95% CI, 0.882 to 0.901) and the morbidly obese group (HR, 0.873; 95% CI, 0.857 to 0.89), compared to reference (normal BMI group). Similar trends were observed for HR of vertebra fracture. The risk of hip fracture was most prominent, the risk of hip fracture increased in the underweight group (HR, 1.896; 95% CI, 1.178 to 2.021) and decreased in the obesity (HR, 0.643; 95% CI, 0.624 to 0.663) and morbidly obesity group (HR, 0.627; 95% CI, 0.591 to 0.665). Lastly, fracture risk was least affected by BMI for limbs.
In T2DM patients, underweight tends to increase fracture risk, and overweight tends to lower fracture risk, but association between BMI and fracture risk varied depending on the affected bone lesions.


Body mass index; Cohort studies; Diabetes mellitus, type 2; Hip fractures; Incidence; Obesity, morbid; Risk factors; Spine


  • Fig. 1. Study design and disposition of subjects. NHIS, National Health Insurance System; FPG, fasting plasma glucose; DM, diabetes mellitus; F/U, follow-up; BMI, body mass index.

  • Fig. 2. Kaplan-Meier estimates of cumulative incidence of fracture in diabetes cohort according to the body mass index (BMI, kg/m2) categories. (A) Total fractures. (B) Vertebral fractures. (C) Hip fractures. (D) Fractures of limbs (upper arm, forearm, and lower leg).

  • Fig. 3. Subgroup analysis by age and sex, presenting the hazard ratios of fractures in diabetes cohort according to the body mass index (BMI, kg/m2) 5 level. (A) Total fractures. (B) Vertebral fractures. (C) Hip fractures. (D) Fractures of limbs (upper arm, forearm, and lower leg).


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