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Diabetes, Osteoporosis, and Fractures

Jul 03, 2013

Seventeen years ago, when I started in my current position as a physical therapist in an endocrine practice, I knew I would be working with people with diabetes and osteoporosis.  What I didn’t realize is how often a person would have both.  I quickly learned about the relationship between osteoporosis and type 1 diabetes.  I have since become very aware of the increased risk of osteoporotic fracture in those with type 2 diabetes.

The National Osteoporosis Foundation (NOF) reports that about 9 million Americans have osteoporosis and an estimated 48 million have low bone density, a risk factor for osteoporosis.  The risk of fracture due to osteoporosis is about one in two women and one in four men over the age of 50.  There are about 2 million fractures costing $19 billion annually!  In addition, hip and vertebral fractures have a high rate of morbidity and mortality.

NOF lists uncontrollable risk factors for osteoporosis of older age (over 50 ?), female, menopause, family history of fracture, being thin/small, and history of fracture as an adult or height loss (possibly due to silent vertebral fractures).  Then, there are the controllable risk factors including insufficient calcium and vitamin D intake; lack of fruits/vegetables in the diet, excessive protein, sodium and caffeine (bummer!); inactive lifestyle; cigarette smoking; excessive alcohol intake; and sudden weight loss (i.e., following gastric bypass surgery).  Several medications are harmful to the bones, including thiazolidinediones (TZDs) and steroids.  Many diseases are associated with osteoporosis including type 1 diabetes, Celiac disease, hyperthyroidism, and hyperparathyroidism.

A meta-analysis by Vestergaard, published in Osteoporosis International in 2009, reported hip fracture risk increased in type 1 diabetes (RR 6.94, 95 percent CI: 3.25-14.78) and in type 2 diabetes (RR 1.38, 95 percent CI: 1.25-1.53) compared to those without diabetes.

The relationship between osteoporotic fracture and type 2 diabetes may be a bit of a surprise.  Many people with type 2 diabetes have bone density that is normal or above normal.  I attended a session at NOF’s Annual Symposium in April, presented by Mishaela Rubin, MD, from Columbia University, who discussed several possible explanations for increased fracture risk including impaired bone strength, treatment with TZDs and falls.

Impaired bone strength can be due to hypogonadism, lack of physical activity, obesity, and possibly insulin use.  Risk of falls for a person with diabetes can be due to peripheral neuropathy, visual disturbances, arthritis/pain, cardiovascular diseases (including arrhythmias and orthostatic hypotension), history of CVA, vitamin D deficiency, polypharmacy, and lower extremity muscle weakness. 

As diabetes educators, what can we do? 

  • Know risk factors for osteoporosis and osteoporotic fracture
  • Discuss use of TZDs with the patient/prescriber
  • Evaluate fall risk and refer for interventions
    • Therapy for balance and strength training
    • Eye and hearing examination
    • Medication review
    • Assistive devices
    • Vitamin D supplementation if deficient
  • Encourage healthy eating, including sufficient calcium and vitamin D intake through foods or supplements, and maintenance of a healthy weight (not under or overweight)
  • Encourage physical activity, especially weight-bearing and resistance trainingEncourage children and teens to adopt healthy bone-building habits.  The majority of bone is accumulated up to the age of 18 making these years most important.

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