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House leaks coincide with overnight rain – diabetics need to be wary of osteoporotic fractures

 Last Update: 2022-10-25
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"House leakage coincides with overnight rain":

Patients with type 2 diabetes have a high incidence of osteoporotic fractures

With lifestyle changes and improved living standards, type 2 diabetes mellitus (T2DM) has become a serious non-communicable chronic disease
worldwide.

The total number of T2DM patients in China ranks first in the world, showing a clear trend of two highs and three ^lows1:

➤Two highs: T2DM prevalence 12.
4%, T2DM pre-prevalence 38.
1%.

➤Three lows: T2DM awareness rate 36.
7%, treatment rate 32.
9%, control rate 50.
1%.

T2DM can cause a variety of chronic complications such as macroangiopathy, retinopathy, nephropathy, neuropathy, etc.
; In recent years, T2DM has increased the risk of fracture and has become increasingly ^important2
.

Just as T2DM is an isocritical condition
of coronary heart disease

T2DM is also an isocritical condition for osteoporotic ^fractures2

Although bone density measured by dual energy X-ray absorptiometry (DXA) reflects fracture risk in non-diabetic patients, it still underestimates fracture risk
in people with type 2 diabetes.
Because diabetics may fracture at relatively high bone mineral density, some glucose-lowering drugs may also affect bone metabolism in diabetics, posing a challenge for clinicians to manage fracture risk in patients with type 2 ^diabetes2
.

"To add insult to injury":

Patients with T2DM are more likely to fracture due to the superposition of internal and external ^factors2

Several epidemiological studies have shown that patients with T2DM have a 38-70% higher risk of fracture than the general population2
.

External causes: easy to ^fall2

Increased nocturia leads to increased nocturnal rises; decreased vision (retinopathy, cataracts); Decreased balance (neuropathy, foot ulcers, amputations); Orthostatic hypotension and hyporesponsiveness are both associated with the susceptibility to falls and fractures in patients with T2DM2
.

Internal causes: decreased bone strength, impaired bone ^quality2

Hyperglycemia caused by the accumulation of glycosylation end products (AGE) in the organic bone matrix, hardening of type I collagen in the bone matrix, decreased bone strength, increased bone fragility, and osteoblastic apoptosis were intuitively manifested as decreased cortical bone thickness and trabecular bone volume, increased cortical bone porosity, and worse bone material ^parameters2
.

In addition to the non-enzymatic glycosylation of collagen, the causes of increased bone fragility in diabetes are multifaceted, including the course of diabetes, insulin resistance, bone marrow fat accumulation, and low levels of bone ^turnover2
.

In addition to the risk factors associated with falls, large fasting blood glucose fluctuations and secondary hyperparathyroidism due to vitamin D deficiency are also internal factors that contribute to the increased risk of fracture in patients with ^diabetes2
.

"Pull out the clouds to see the sun": use reasonable indicators,

Better assess fracture risk in patients with T2DM

Bone mineral density

Measuring bone density by dual-energy x-ray absorptiometry (DXA) is a common clinical method for
determining osteoporosis and fracture risk.
But DXA could not detect a decrease in bone strength; and damage to the cortical bone microstructure is more obvious in patients with diabetic microangiopathy; That is, the bone density measured by DXA does not fully reflect the damaged bone quality of
T2DM patients.
This makes it tricky for clinicians to accurately assess fracture risk in patients with ^diabetes2
.

FRAX online assessment

This online tool recommended by the World Health Organization contains 12 factors (gender, age, height, weight, previous fragility fracture history, parental history of hip fracture, presence or absence of rheumatoid arthritis, etc.
).

Replacing "rheumatoid arthritis" with diabetes, increasing the patient's age by 10 years, or subtracting bone density T-values by 0.
5 can help improve the predictive risk of fracture in patients with ^T2DM3
.

Figure 1: FRAX is an online software that uses clinical risk factors to assess each individual's risk of developing an osteoporotic ^fracture3
.

QCT (quantitative computed tomography)

QCT stands for Quantitative Computed Tomography, which is a method of
measuring bone density on CT equipment.
This method reflects the loss of cancellous bone in the vertebral body by measuring the bone density of the lumbar
spine.
Clinically, QCT can be used to predict the risk of vertebral fracture in postmenopausal women and observe the efficacy of osteoporosis ^drugs4
.

Diabetic patients with DXA bone density testing are often affected by obesity and spinal degeneration such as osteohyperplasia and osteoarthritis, and bone density measurement values are often higher than true bone density, resulting in missed osteoporosis
.
In this case, the use of QCT can avoid these effects and make it more accurate to detect osteoporosis
in diabetic patients.
Therefore, for diabetic patients who are overweight and obese or have more degenerative diseases of the spine, it is recommended to choose lumbar spine QCT as an osteoporosis
evaluation tool.
According to the recommendations of the American Society of Radiology and the International Society for Clinical Bone Densitometry, the threshold <of trabecular bone density measured by QCT is 120 mg/cm3 for osteopenia <and 80 mg/</b23>

"Plan ahead": Avoid use

T2DM drugs that may increase the risk of fracture

The effects of hypoglycemic drugs on bone metabolism are attracting increasing attention
.
This is primarily because thiazolidinedione (TZD) drugs such as rosiglitazone and pioglitazone ^{are associated with} an increased risk of fracture2
.

In addition, the effects of sulfonylurea-induced hypoglycaemia on falls and fractures, such as when sulfonylureas are used in combination with ^{TZDs, should} also be vigilant2
.

Patients with T2DM who take insulin tend to have a longer course of disease, have multiple complications, and are at higher risk of hypoglycaemia after insulin injection, which also increases the risk of falls and fractures in patients with ^T2DM2
.

"Entrenched":

Reasonable nutrition, correct prevention and treatment of osteoporotic fractures

Lifestyle adjustments and the intake of basic supplements for bone health are the basic measures to
prevent osteoporosis.
Lifestyle modifications, including a balanced diet rich in calcium, salt and moderate protein, and avoiding excessive consumption of coffee and carbonated beverages; Quit smoking and limit alcohol, exercise regularly4
.

Calcium, magnesium, vitamin D, vitamin K and other nutrients are closely related to bone ^health6; Calcium and vitamin D are essential supplements for bone health and the basis for osteoporosis ^treatment4
.
Adequate intake of calcium and vitamin D is essential
.
According to the latest nutritional survey results, the dietary intake of calcium in China is about 356mg/d⁷; The recommended daily intake of calcium is 800mg/d for adults and 1000mg/d for people over 50 years old; The difference between the recommended intake and the actual intake is about 500-600mg^/
day6.

The Expert Consensus on Nutrition and Exercise Management in Patients with Primary Osteoporosis 2020 recommends: "Insufficient dietary calcium intake can be supplemented with calcium preparations
.
Calcium containing
500-600 mg of elemental calcium can be taken orally daily.
Many patients believe that bone problems should be attributed
to orthopedics.
In fact, osteoporosis, like other chronic diseases, requires not only lifestyle improvement, but also long-term, individualized drug ^treatment4; The Department of Orthopedics is mainly responsible for the treatment after fractures, while the Department of Endocrinology and Metabolism is responsible for the diagnosis and treatment
of osteoporosis.
The treatment of osteoporosis is not enough to rely on basic measures such as calcium supplementation and vitamin D; On the basis of ensuring basic measures, after the evaluation and guidance of specialists, the scientific use of anti-osteoporosis drugs such as bisphosphonates can effectively "transport" the calcium eaten into the bones, thereby improving bone density, improving bone quality, and reducing the risk of ^fractures4
.

"Multi-pronged approach", check "leaks" and make up "gaps"

Endocrinologists should take a multi-pronged approach to risk the fracture of
diabetic patients.

Figure 2: International Osteoporosis Foundation (IOF) fracture risk assessment process for diabetic ^patients8

Patients with T2DM should cooperate with their doctor to check for gaps and stay away from osteoporotic fractures
.

➤Endocrinologist: When newly diagnosed with T2DM patients, comprehensive analysis of DXA and bone metabolism indicators; Try to avoid drugs that may affect bone metabolism; Patients are advised to supplement with adequate calcium and vitamin D
at a reasonable level.

➤T2DM patients: cooperate with doctors to actively control blood sugar, prevent complications, and treat osteoporosis; Adopt a healthy lifestyle, moderate exercise, balanced diet; Take a variety of precautions to reduce the risk of
falls.

Figure 3: Precautions for T2DM osteoporosis9

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References:

Prevalence and Treatment of Diabetes in China, 2013-2018.
JAMA.
2021 Dec 28; 326(24):2498-2506.
Osteoporosis and Bone Mineral Salt Disease Branch of Chinese Medical Association, Endocrinology Branch of Chinese Medical Association, Diabetes Branch of Chinese Medical Association.
Chinese expert consensus on fracture risk management in diabetic patients[J].
Chinese Journal of Endocrinology and Metabolism,2019, 035(7):535-547.
)
_msthash="583456" _msttexthash="10066927">Guidelines for diagnosis and treatment of primary osteoporosis(2017)[J].
Chinese Journal of Practical Internal Medicine, 2018,038(002):127-150.
)
Comparison of Quantitative Computed Tomography and Dual X-Ray Absorptiometry: Osteoporosis Detection Rates in Diabetic Patients.
Cureus.
2022 Mar 13; 14(3):e23131.
Expert consensus on nutrition and exercise management of patients with primary osteoporosis[J].
Chinese Journal of Osteoporosis and Bone Mineral Salt Diseases,2020,13(5):396-410.
)
Energy and main nutrient intake of Chinese residents from 2015 to 2017[J].
Food and Nutrition in China, 2021.
Bone and Diabetes Working Group of IOF.
Diagnosis and management of bone fragility in diabetes: an emerging challenge.
Osteoporos Int.
2018 Dec; 29(12):2585-2596
Sweet Bones: The Pathogenesis of Bone Alteration in Diabetes.
J Diabetes Res.
2016

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