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Nat. Rev. Endocrinol. doi:10.1038/nrendo.2016.153 Figure 2 Cellular and molecular mechanisms of bone diseases in diabetes mellitus Figure 2 | Cellular and molecular mechanisms of bone diseases in diabetes mellitus. Although several reports consistently indicate an increased risk of fractures in patients with diabetes mellitus, the underlying mechanisms are unclear and there is not enough evidence for a conclusive model of bone fragility in diabetes mellitus; however, some factors should be highly considered. With the decline of β-cell function, chronic hyperglycaemia causes oxidative stress, inflammation, the production of reactive oxygen species (ROS) and advanced glycation end products (AGEs), causing organ damage and reduced bone strength. In particular, accumulation of AGEs in diabetic bone collagen determines reduced material properties and increased susceptibility to fracture. AGEs and hyperglycaemia also directly inhibit bone formation via suppression of osteoblast function. Low bone formation is also caused by disturbances to the WNT signalling pathway, with increased SOST expression, higher sclerostin levels and decreased levels of insulin-like growth factor-binding protein 2 (IGFBP2) and protein Wnt10b (Wnt10b). In type 1 diabetes mellitus (T1DM) and in the late stages of type 2 diabetes mellitus (T2DM), bone formation is also decreased by insulin deficiency through an inhibitory effect on osteoblasts, either directly or through alterations in insulin-like growth factor 1 (IGF1) levels. Other factors typically linked to T2DM and obesity interfere with bone health. Dysregulation of adipokines like adiponectin and leptin have a negative effect through complex central and peripheral mechanisms. New evidence also indicates a negative effect on bone health by loss of the incretin effect, with reduced bone formation and increased osteoclatogenesis. Finally, alterations of the calcium–parathyroid hormone (PTH) axis result in a negative calcium balance, thereby contributing to bone demineralization in diabetes mellitus. GI, gastrointestinal; GIP, gastric inhibitory polypeptide; GLP1, glucagon-like peptide 1. Napoli, N. et al. (2016) Mechanisms of diabetes mellitus-induced bone fragility Nat. Rev. Endocrinol. doi:10.1038/nrendo.2016.153