Background: Trabecular bone score (TBS) independently predicts diabetic bone disease. Many studies have compared TBS in those with and without diabetes, showing inconsistent results. We conducted a systematic review and meta-analysis to evaluate TBS in type 2 diabetes mellitus (T2DM) and clarify its role, considering gender and other confounders.

Methodology: Relevant studies were systematically searched until October 2024 using related terms across multiple databases. RevMan Web and R software were employed to conduct statistical analyses. Meta-analyses utilized random-effects models and the inverse variance statistical method; results were expressed as mean differences (MD) with 95 % confidence intervals. The primary outcome of interest was the MD in TBS (unadjusted or adjusted) between the T2DM and non-diabetes groups.

Results: Data from 27 studies with 16,354 subjects were analyzed. Compared to controls without diabetes, subjects with T2DM exhibited lower unadjusted TBS in the combined sex group (MD -0.10 [-0.18, -0.02], P = 0.01), as well as in men (MD -0.02 [-0.04, -0.00], P = 0.02) and women (MD -0.05 [-0.07, -0.03], P < 0.0001). Individuals with T2DM also had a lower adjusted TBS in the combined sex group (MD -0.16 [-0.24, -0.08], P < 0.0001), men (MD -0.02 [-0.04, -0.00], P = 0.02), and women (MD -0.04 [-0.06, -0.02], P = 0.0005). While lumbar spine bone mineral density (BMD) was higher in individuals with T2DM than in those without across all three groups, total hip BMD was higher in women and the combined sex group; femoral neck BMD was higher only in the combined sex group.

Conclusion: According to the data analyzed in this updated meta-analysis, T2DM appears to adversely affect TBS, despite having a positive effect on BMD; however, the evidence level is very low. Larger and longer-term studies are necessary to explore the implicated factors and potential remedial strategies.

PROSPERO registration number: CRD42024608004