Aims <p>This study aimed to investigate the association between early-onset type 2 diabetes (EOT2D) and the risk of falls, focusing on the role of sarcopenic obesity.</p> Methods <p>A total of 580 patients (290 with EOT2D and 290 with late-onset type 2 diabetes [LOT2D]) were selected through propensity score matching. Participants were categorized into four groups: non-sarcopenia/non-obesity, obesity-only, sarcopenia-only, and sarcopenic obesity. Binary logistic regression models were employed to examine the relationships between age at diabetes onset, sarcopenic obesity, and fall risk. Additionally, 472 patients were followed longitudinally to assess the associations between EOT2D, LOT2D, sarcopenic obesity, and fall risk.</p> Results <p>Patients with EOT2D exhibited a higher prevalence of sarcopenic obesity compared to those with LOT2D. EOT2D was significantly associated with an increased risk of falls, both directly and indirectly via sarcopenic obesity (β = 0.81, OR_SO−VFA = 2.25, 95% CI: 1.79–2.82). EOT2D patients with sarcopenic obesity, particularly characterized by visceral fat area (VFA), demonstrated a substantially higher fall risk (HR_{EOT2D+SO−VFA} = 3.98; 95% CI: 2.57–6.16) compared to those with sarcopenia or obesity alone.</p> Conclusions <p>Patients with EOT2D are more prone to developing sarcopenic obesity, and visceral obesity contributes to the elevated risk of falls in this population. Therefore, interventions to preserve muscle mass and strength while reducing visceral fat accumulation are critical in mitigating fall risk among patients with EOT2D.</p> Graphical Abstract <p></p>