Diabetes and osteoporosis are both diseases of epidemic proportions whose incidence is increasing worldwide. The etiology of osteoporosis is multifactorial and may differ for type 1(T1DM) as compared to type 2 (T2DM). Fragility fractures are common to both types of diabetes with hip fractures occurring more frequently in the elderly T2DM population. The use of oral PPAR gamma agonists in the treatment of T2DM has also added to the risk of fracture. This perspective discusses the etiologies and issues relating to the association of diabetes with osteoporosis and fractures and suggests some theories to clarify the underlying pathophysiology. Unfortunately at this time treatment for osteoporosis and fractures remains empirical.