Background <p>Lipid accumulation product index (LAPI) is a new indicator for evaluating visceral obesity and has been used in the assessment of risk of diabetes and diabetic kidney disease, however the association with the risk of osteoporosis (OP) in patients with type 2 diabetes mellitus (T2DM) remains unclear.</p> Objective <p>We aimed to determine the association between the lipid accumulation product index (LAPI) and osteoporosis (OP) risk in elderly patients with type 2 diabetes mellitus (T2DM).</p> Methods <p>A total of 1280 patients with T2DM aged over 60&#xa0;years were divided into OP and non-OP groups, and the LAPI levels were compared, patients were categorized into Q1, Q2, Q3, and Q4 groups based on quartiles of LAPI, and the prevalence of OP was compared. Correlation between the LAPI and risk of OP in male or female was analyzed by multivariate logistic regression and subgroup analyses.</p> Results <p>LAPI levels were significantly higher in OP group (50.80 ± 16.95) than in the non-OP group (45.64 ± 14.38, <i>p</i> &lt; 0.05), the prevalence of OP was significantly higher in the Q4 group than in the Q1, Q2, and Q3 groups. Multivariate regression analyses showed that compared with the Q1 group, people in the Q4 group had a higher risk of OP, the OR was 2.748 (95% CI (1.933, 3.905), <i>p</i> &lt; 0.05) in all participants, the OR was 3.787 (95% CI (2.259, 6.350), <i>p</i> &lt; 0.05) in male, and the OR was 2.136 (95% CI (1.245, 3.664), <i>p</i> &lt; 0.05) in female. Subgroup analyses revealed a stronger positive association between LAPI and OP risk when sex was male, smoking history was yes, and drinking history was yes.</p> Conclusion <p>Patients with OP have higher levels of LAPI. In elderly patients with T2DM, LAPI levels was independently positively correlated to risk of OP prevalence, and This relationship may be stronger in overweight patients, those with higher levels of glycosylated hemoglobin, and those who smoke or drink alcohol.</p>