Type 2 Diabetes and Bone Fractures

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Type 2 Diabetes and Bone Fractures
« on: July 10, 2009, 12:30:08 PM »
By Simeon Margolis, M.D., Ph.D

Obesity is generally associated with a greater amount of bone mineral (as measured by bone mineral density, or BMD) and a lower likelihood of bone fractures.

But even though most women with diabetes are overweight or obese and have normal, or even high, measures of BMD, a number of studies have now shown that older women with diabetes in fact suffer more bone fractures than do non-diabetic women of the same age. The hip is the most frequent site for these excess fractures. Whether older men with diabetes are also at increased risk for bone fractures is not yet clear

Interestingly, women with pre-diabetes (fasting blood glucose levels between 100 and 125 mg/dL) have no greater risk of fractures than do women with normal blood glucose levels.

Why should women with diabetes have more fractures, even though their BMD levels are normal or high? One answer is that they tend to have more falls than non-diabetic women. Diabetes can cause visual difficulties and loss of normal sensation in the feet and legs (peripheral neuropathy), which may contribute to a greater number of falls. Falls are also more likely in women who are being treated with insulin or—curiously—who have the lowest levels of blood glucose and HbA1C, findings that might suggest that some of the excess falls in women with diabetes may be related to episodes of hypoglycemia (low blood glucose).

In addition, there is convincing evidence that treatment with the thiazolidinediones, either Avandia or Actos, raises the number of bone fractures. The other oral medications used to control blood glucose do not increase the risk of fractures.

So, if you're a woman with diabetes, please do not immediately assume that you are protected from fractures, even when your doctor gives you the good news that your DEXA scan (the common test for BMD) has shown a normal or high BMD. Regardless of your BMD numbers, if you have diabetes you need to take extra precautions against falls. And you would probably do well to also control your weight and to exercise regularly to build strength in your leg muscles. Exercise and, if needed, weight loss both aid in keeping glucose levels in check, thus reducing the likelihood of visual loss and the development of peripheral neuropathy.

And while we're on the subject of blood glucose levels, 2 large studies recently showed that overzealous lowering of blood glucose did not reduce the incidence of heart attacks or prolong life in people with type 2 diabetes. In fact, study participants whose blood glucose was treated more intensively than average had a higher mortality than those treated more moderately. These findings in no way reduce the need for people with diabetes to maintain good blood glucose levels to protect against late complications. However, as these 2 studies show, both the greater mortality and fracture risk with very tight control suggest that older women should not strive to achieve HbA1C levels less that 7.0.