Diabetes & The Body

Osteoporosis in diabetics: An Overlooked Disease

Osteoporosis is one of the most prevalent metabolic bone disease in the world, characterized by low bone mass, increased fragility, decreased bone quality, and an increased risk of fracture. However, the risk its impact on diabetic persons is often not considered. Although osteoporosis traditionally has not been listed as a complication of diabetes, patients with either type 1 or type 2 diabetes are among those at increased risk for this condition.

Routine screening or initiation of preventive medications for osteoporosis in diabetic patients is not recommended, but all diabetics, particularly those with fractures, should be given general recommendations regarding adequate dietary calcium intake, regular exercise, and avoidance of other potential risk factors.

Consideration of bone density evaluation should be part of the fracture evaluation, and respective preventive or therapeutic interventions should be applied.

Assessment of Risk Factor

Bone mineral density (BMD) obtained with the help of a dual X-ray absorptiometry (DXA) is the most common standard tool for bone mass assessment although it is not a perfect diagnostic tool due to the fact that there are many micro-architectural bone qualities and bone geometries that are not detectable through DXA.

A comprehensive risk assessment for osteoporosis should therefore include:

• falls risk assessment
• visual acuity testing
• nutrition evaluation

Low bone density and diabetes

Type 1 diabetes has long been associated with low bone density. However, it was unclear until recently whether this translated into increased fracture rates. Further diabetic retinopathy, advanced cortical cataracts, and diabetic neuropathy have all been associated with increased fractures. These factors put a diabetic person at risk for increased falls because of visual impairment and alterations in balance or gait.

Therefore it becomes imperative that diabetics presenting with an osteoporosis-related fracture should also have vision and balance evaluations.

Besides, in case of persons with type 1 diabetes, the initial onset of the disease often occurs at a young age, when bone mass is still being formed. Although levels of glucose control among this population has not been correlated with the severity of osteoporosis, studies have shown that bone resorption is decreased during periods of high blood glucose. When considering all of the risk factors, patients with diabetes generally have an increased risk of falling because of peripheral neuropathy, possible hypoglycemia, increased secretion of urine during night (nocturia), and visual impairment.

Risk Factors for Falls

Studies related to osteoporotic fractures have confirmed that older women with type 2 diabetes experience higher fracture rates than do non-diabetic women in regions of the hip, bone extending from the shoulder to the elbow (humerus), and foot.

Besides, bone loss has been observed be greater in patients with poorly controlled diabetes than in those whose diabetes is in good control.

Treatment Options for Osteoporosis

The following are known to have an impact on the development and maintenance of adequate bone mass and density, besides playing their respective roles in bone development and maintenance.

1. Proteins
2. Minerals such as phosphorus, calcium, manganese and zinc
3. Vitamins C, D, and K
4. Fluoride

Other factors considered when evaluating the optimal nutritional intervention for prevention and management of osteoporosis are:

1. Body weight
2. Intake of caffeine
3. Sodium intake
4. Calcium-to-phosphorus ratio

However, in most countries, the intake of dietary calcium, particularly in females, is documented to be below the recommended levels for optimizing bone mass during growth and minimizing bone loss during aging. As a result of this, the focus of nutrition recommendations for osteoporosis has been on this vital mineral. According to the recommendations of The National Osteoporosis Foundation, all adults need to receive at least 1,200 mg/day of elemental calcium and 400-800 IU/day of vitamin D.

Some common dietary supplements that are helpful in meeting the target intake are:

1. Milk and diary products
2. Soya beans
3. Spinach, broccoli and other cooked greens
4. Eggs and fish

About 90 percent of our vitamin D supply comes from the skin's production of this nutrient through sunlight activation. This is the reason why Vitamin D deficiencies can easily occur in people who spend most of their time indoors. A main role of vitamin D in bone health is to promote intestinal calcium absorption. Therefore, vitamin D and calcium impact osteoporosis in an interdependent manner.

However, excessive intake of vitamin D, can lead to toxicity besides promoting calcification of soft tissue, particularly in the kidney.

Women who are lean are known to be at a higher risk of developing osteoporosis when compared to heavy women. However, obesity and overweight are associated with co-morbidities including type 2 diabetes, hypertension, cardiovascular disease, and hypertension. Therefore, nutritional intervention needs to include weight management such that body weight falls within the acceptable BMI range. This can be achieved with the help of exercise as in addition to yielding improvements in bone mass, exercise also improves overall muscle strength, which is important in preventing falls.

However, patients who have vertebral osteoporosis, for example, should avoid back flexion exercises, particularly those involving weights, because such activities can increase fractures. Further, stretching, strengthening, impact, and balance exercises are effective ways to improve flexibility and prevent falls.

Apart from the use of prescription agents available for osteoporosis treatment, patients with diabetes should be educated about the following:

• BMD (Bone Mineral Density) screening is necessary for all postmenopausal women > 65 years of age and of those < 65 who are in high-risk groups.
• Patients with low bone density or high falls risk should wear hip protectors, as these devices have been reported to reduce the risk of hip fractures by about 60%.
• Proper nutrition should include a variety of calcium-containing foods. Exercise, including a balance program, is also important.
• Home safety measures should be implemented to reduce hazards around the home that could increase the risk of falls.