# Sex-specific associations between carotid plaque and bone mineral density in patients with type 2 diabetes: a retrospective cross-sectional study

## TL;DR

In women with type 2 diabetes, having carotid plaque is linked to worse bone health, but this connection isn't seen in men.

## Contribution

This study reveals sex-specific associations between carotid plaque and bone mineral density in type 2 diabetes patients.

## Key findings

- In women with T2DM, carotid plaque is independently linked to worse osteoporosis categories.
- Men with carotid plaque had slightly higher spine bone density but no significant osteoporosis risk differences.
- The study highlights the need for sex-specific approaches to monitoring bone health in T2DM patients.

## Abstract

Carotid plaque and osteoporosis commonly coexist in type 2 diabetes mellitus (T2DM), but whether their association differs by sex remains unclear. We examined sex-specific differences in bone measures and the adjusted association between carotid plaque and osteoporosis status in patients with T2DM.

This retrospective cross-sectional study included 1,224 patients with T2DM (794 women and 430 men). Carotid plaque was assessed by ultrasound. Lumbar spine bone mineral density (BMD) and T-scores were measured by dual-energy X-ray absorptiometry (DXA), and osteoporosis status was categorized as normal bone mass, osteopenia, or osteoporosis. Clinical characteristics, bone measures, and osteoporosis prevalence were compared between patients with and without carotid plaque within each sex. Sex-stratified ordinal logistic regression models were used to evaluate the adjusted association between carotid plaque and osteoporosis categories with stepwise adjustment for BMI, diabetes duration, lipid parameters, and glycemic indices.

In men, patients with carotid plaques showed a modestly higher lumbar spine BMD (P = 0.013); however, lumbar spine T-scores and osteoporosis prevalence were similar between plaque and non-plaque groups, and no adjusted association with osteoporosis category was observed across models. In women, lumbar spine BMD, T-scores, and osteoporosis prevalence were similar between plaque and non-plaque groups in unadjusted comparisons. However, in women, carotid plaques were independently associated with higher odds of worse osteoporosis category after adjustment (Model 1: odds ratio (OR) 1.40 [95% confidence interval (CI) 1.05–1.85]; Model 2: OR 1.45 [95% CI 1.09–1.92]; Model 3: OR 1.50 [95% CI 1.12–1.99]; all P < 0.05).

Among patients with T2DM, carotid plaque was independently associated with worse osteoporosis category in women but not in men. These findings indicate sex-specific associations between carotid atherosclerosis and skeletal health; however, given the cross-sectional design and unavailable key confounders (e.g., lifestyle factors, central adiposity measures, medication patterns, and fracture outcomes), the results should be interpreted as associative and require confirmation in prospective studies.

The online version contains supplementary material available at 10.1186/s13293-026-00830-y.

People with type 2 diabetes often develop fatty “plaques” in the arteries of the neck (carotid plaques). Many also have low bone density, which increases the risk of osteoporosis and fractures. We studied whether having carotid plaque is linked to poorer bone health, and whether this relationship differs between women and men. We reviewed medical records from 1,224 adults with type 2 diabetes who had both a carotid ultrasound and a bone density scan. We compared bone density results between people with and without carotid plaque, separately for women and for men. We also accounted for factors that can affect both artery disease and bone health, such as body weight and diabetes-related measures. In men, those with carotid plaque had slightly higher spine bone density, but their overall bone density categories were similar to men without plaque. In women, average bone density values looked similar between groups, but after accounting for other health factors, women with carotid plaque were more likely to fall into a worse bone-density category. Because this study looked at information from a single point in time, it cannot prove that carotid plaque causes osteoporosis. However, our findings suggest that women with type 2 diabetes who have carotid plaque may benefit from closer attention to bone health and screening for osteoporosis.

The online version contains supplementary material available at 10.1186/s13293-026-00830-y.