Are people with diabetes more likely to have osteoporosis, bone fractures?
The woman sitting across the table was distressed. She was 60 years old and had diabetes for 20 years. “Two months ago, I developed a bout of coughing, followed by a sharp back pain. The doctor asked for an X Ray and told me that I had fractured my spine! Nothing hit me, I did not fall. It was just a bad coughing spell. How did I break my vertebra?” The pain was severe for a few weeks but gradually settled and she was then allowed to move around with a brace. The woman had osteoporosis, a condition characterised by porous, fragile bones, which break with minimal or no trauma. Usually, weak bones do not result in pain unless they break, and a fracture is often the first clinical symptom.
What is osteoporosis?
Our skeleton provides a frame for our body and protection for the organs within, much like the metal beams and girders that support buildings. Like metal, bones also suffer wear and tear. Unlike metal, however, bones are living tissues and have a remarkable capacity to regenerate and heal. Sites of minor damage are constantly replaced by new, healthy bones. When the capacity of the body to form new bone is unable to keep up with bone loss, there is progressive weakening, resulting in osteoporosis.
During childhood and adolescence, our skeleton grows rapidly. Enabled by vitamin D, the skeleton builds its calcium stores, particularly during puberty. Boys have bigger bones than girls, and accumulate more minerals over a longer period of time. From the age of 30, we begin to lose bone gradually, a process that is accelerated at menopause in women. If left unchecked, this loss gradually weakens the bones, making them brittle and resulting in fractures. Typically, fractures due to osteoporosis occur at the hip, spine, shoulder or wrist and can have a life-changing impact.
Why are diabetics at greater risk of bone fractures?
People with diabetes have a greater risk of breaking their bones. In those with childhood onset, insulin-dependent type 1 diabetes, this risk is increased by two to four-fold. In those with type 2 diabetes, the risk of fracture is 30-50 per cent higher as compared to those without diabetes. We know that diabetes can result in several chronic complications, involving the heart, kidney, eyes and nerves. Fragility fractures can be regarded as a consequence of diabetes too.
Typically, it requires about 10 years (minimum five years) of diabetes to impact fracture risk. Poorly-controlled diabetes with complications confers a greater risk of fracture. Importantly, people with diabetes fracture at a higher bone density than those without diabetes. The T score is a number shown on the DXA bone density report. Typically, fracture risk is thought to increase if the bone density shows a T score of below -2.5, whereas in diabetes this figure is -2. This means that people with diabetes may require intervention earlier, maybe at a T score of -2 rather than -2.5. If they get a fracture, people with diabetes take longer to recover and have poorer outcomes, particularly after hip fracture.
Why are people with diabetes more prone to osteoporosis?
First, people with uncontrolled, long-standing diabetes have poor quality bones, which fracture easily. Second, they have lower muscle mass, which indirectly impacts their bone strength, and also makes them more prone to falling and breaking a bone. Third, older people with diabetes often have associated visual issues or nerve-related issues, which again put them at greater risk of falls and fractures.
How can people with diabetes reduce their risk of fractures?
1) Testing : People with diabetes should get their bone density checked at the age of 50 if they have had diabetes for more than 10 years. For those over 60, it makes sense to have your bone density checked anyway. A T score of below -2 requires attention. Your doctor will decide if you need medication or not. However, routinely checking BMD in younger people – below the age of 50 – is NOT recommended, even if they have diabetes.
2) Control your sugars: Good control of diabetes will protect your bones along with other organs.
3) Calcium: An adequate calcium intake is a must for our bones and dairy products are the main source of calcium. If you have milk allergy, lactose intolerance, vegan habits, or just don’t like milk, you may require supplements, to reach a daily intake of 800-1000 mg.
4) Vitamin D: This plays a crucial role in bone health, and urban Indians are commonly vitamin D-deficient. Increasing sunlight exposure can be a challenge because of the heat in summer and pollution in winter. Please make sure that you use vitamin D fortified milk products and take supplements as directed (1000-2000 IU/day).
5) Dietary protein: Proteins are important for our bones and critical for our muscle mass. Indian diets are often low in protein. Next time you visit the nutritionist/educator, don’t just discuss sweets. Find out ways to enhance your protein intake, to achieve at least 0.8gm/ kg of body weight daily.
5) Exercise: All kinds of exercise help in strengthening our muscles and bones, but weight-bearing exercises (exercising in erect posture) and resistance-training are the most effective.
6) Giving up smoking and controlling alcohol intake help keep our bones healthy.
7) Medication: If your doctor decides you need medication for your bones, even if you do not have any symptoms, please comply. It is similar to treating high BP, cholesterol or sugar, all of which produce no symptoms but can insidiously lead to long-term complications. Modern medication can reduce your fracture risk by half.
If you follow these principles, you can save your bones and reduce your fracture risk considerably.