Standard bone examination may not pick up fracture risk in diabetics

by Barbara Hewitt on December 15, 2016

Doctors and nurses are being urged to be more aware that people with diabetes are more prone to broken bones with research suggesting standard assessment may not be sufficient.

Researchers from the University of Manitoba in Winnipeg, Canada, point out that the heightened risk is seen in people with type 1 and type 2 diabetes and their bone health needs to be monitored.

BonesThey point out that the prevalence of osteoporosis in people with diabetes, particularly type 2, is expected to increase as the world’s population ages and gets more obese.

Isanne Schacter and William Leslie say in their scientific paper that they set out to determine whether they could account for the excess fracture risk in people with type 1 and type 2 diabetes and see if standard assessments could be adjusted to make them more accurate.

They also studied the Fracture Risk Assessment Tool (FRAX), which is incorporated into modern DXA scanners and is already known to underestimate fracture risk in people with type 2 diabetes due to their general higher body mass index (BMI) as well as their risk of falling and subsequent changes in bone density.

“It is our hope that doctors can use the adjustments outlined in our paper to approximate the true fracture risks of someone with diabetes,” Dr Leslie told Medscape Medical News.

Bone specialists have long known about the relationship between diabetes and the risk of broken bones, but many non-specialists often overlook the risk, according to Leslie. ‘The fracture risk is higher than you would expect, given their level of bone density,’ he explained.

He explained that as well as weight other reasons for the increased fracture risk is that complications of diabetes, such as impaired vision, balance, and neurological function, put these patients at an increased risk for falling, which will increase the possibility of fractures even if the bone itself is unaffected.

‘There is accumulating evidence that the advanced glycosylated end products [AGES] seen with diabetes interfere with normal bone renewal and bone strength, and there is evidence suggesting that the bones of people with diabetes are probably softer,’ he pointed out.

There is also evidence that bone porosity is increased, especially within the dense cortex of the bone, which makes the bone much weaker than one might predict, relative to the amount of bone,’ he said.

He added that also, among people with type 1 diabetes, poor metabolic control may lead to increased bone resorption and bone loss in young adults, coupled with decreased bone formation retarding bone accumulation during growth, ultimately leading to the development of osteopenia.

It is estimated that people with type 1 diabetes have a relative increase in the risk of hip fracture of 6.4 to 6.9 fold compared with those without diabetes, which vastly exceeds the relative risk of 1.42 expected from the magnitude of the BMD reduction. Among people with type 2 diabetes, a lower BMD correlates with a higher fracture risk, just as it does in the general population.

‘However, the increased fracture risk associated with type 2 diabetes is not fully captured by BMD that is paradoxically higher, even after adjustment for the BMI. Type 2 diabetes upshifts the BMD fracture relationship such that there is an increase in fracture risk above that predicted from BMD alone, resulting in the additional fracture burden attributable to type 2 diabetes,’ Leslie said.

He concludes that while the tools used to assess fracture risk in the general population, such as DXA, are good, they’re not well tuned to the needs of people with diabetes.


The opinions expressed in this article do not necessarily reflect the views of the DiabetesForum.com Community and should not be interpreted as medical advice. Please see your doctor before making any changes to your diabetes management plan.

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