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Dou J, Wang J, Zhang Q. Differences in the roles of types 1 and 2 diabetes in the susceptibility to the risk of fracture: a systematic review and meta-analysis. Diabetol Metab Syndr 2021; 13:84. [PMID: 34399851 PMCID: PMC8369647 DOI: 10.1186/s13098-021-00687-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/08/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) causes excess risk of fracture at varied sites. Whereas, the difference between the roles of types 1 DM (T1DM) and 2 DM (T2DM) diabetes in the risk of fractures remains limited and inconclusive. We, therefore, conducted a meta-analysis to assess the differences for the associations of T1DM and T2DM with the risk of fractures. METHODS We systematically searched PubMed, Embase, and the Cochrane library for eligible studies until May 2021. The odds ratios (ORs) with 95% confidence intervals (CIs) were used to calculate the pooled effect estimates for the associations of T1DM and T2DM with the risk of fractures using the random-effects model. An indirect comparison results for the ratio of OR (ROR) with 95% CI were also applied to assess the difference between T1DM and T2DM with the risk of fractures. RESULTS Twenty-two cohort studies involving a total of 6,484,851 individuals were selected for meta-analysis. We noted that T1DM was associated with an increased risk of all fractures (OR: 1.72; 95% CI 1.36-2.19; P < 0.001), and fractures at the hip (OR: 4.01; 95% CI 2.90-5.54; P < 0.001), upper arm (OR: 2.20; 95% CI 1.61-3.00; P < 0.001), ankle (OR: 1.97; 95% CI 1.24-3.14; P = 0.004), and vertebrae (OR: 2.18; 95% CI 1.85-2.57; P < 0.001). Moreover, T2DM induced excess risk to all fractures (OR: 1.19; 95% CI 1.09-1.31; P < 0.001), including fractures at the hip (OR: 1.25; 95% CI 1.15-1.35; P < 0.001), upper arm (OR: 1.42; 95% CI 1.20-1.67; P < 0.001), and ankle (OR: 1.15; 95% CI 1.01-1.31; P = 0.029). Furthermore, we noted that T1DM versus T2DM was associated with greater risk to all fractures (ROR: 1.45; 95% CI 1.12-1.87; P = 0.005), including fractures at the hip (ROR: 3.21; 95% CI 2.30-4.48; P < 0.001), upper arm (ROR: 1.55; 95% CI 1.09-2.20; P = 0.015), and ankle (ROR: 1.71; 95% CI 1.06-2.78; P = 0.029). CONCLUSIONS This study found that T1DM caused an excess risk to all fractures, including fractures at the hip, upper arm, and ankle than T2DM. Further studies should therefore be conducted to directly compare the differences between T1DM and T2DM with the risk of fractures at various sites.
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Affiliation(s)
- Jiaqing Dou
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Shushan District, Hefei, 230022, Anhui, China
- Department of Endocrinology, Chaohu Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jing Wang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Shushan District, Hefei, 230022, Anhui, China
- Department of Endocrinology, Chaohu Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qiu Zhang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Shushan District, Hefei, 230022, Anhui, China.
- Department of Endocrinology, Chaohu Affiliated Hospital of Anhui Medical University, Hefei, China.
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Wang N, Zhang M, Ji J, Li D, Hu L, Meng J, Yu B. Type 2 diabetes mellitus and the risk of hip and vertebral fractures: a systematic review and meta-analysis of cohort studies. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-00973-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Vilaca T, Paggiosi M, Walsh JS, Selvarajah D, Eastell R. The Effects of Type 1 Diabetes and Diabetic Peripheral Neuropathy on the Musculoskeletal System: A Case-Control Study. J Bone Miner Res 2021; 36:1048-1059. [PMID: 33825260 DOI: 10.1002/jbmr.4271] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 12/22/2022]
Abstract
Fracture risk is increased in type 1 diabetes (T1D). Diabetic neuropathy might contribute to this increased risk directly through effects on bone turnover and indirectly through effects on balance, muscle strength, and gait. We compared patients with T1D with (T1DN+, n = 20) and without (T1DN-, n = 20) distal symmetric sensorimotor polyneuropathy and controls (n = 20). We assessed areal bone mineral density (aBMD) and appendicular muscle mass by dual-energy X-ray absorptiometry, microarchitecture by high-resolution peripheral quantitative tomography at the standard ultra-distal site and at an exploratory 14% bone length site at the tibia and radius, bone turnover markers, and muscle strength, gait, and balance by Short Physical Performance Battery (SPPB). At the standard ultra-distal site, tibial cortical porosity was 56% higher in T1DN+ compared with T1DN- (p = .009) and correlated positively with the severity of neuropathy (Toronto Clinical Neuropathy Score; r = 0.347, p = .028) and negatively with nerve conduction amplitude and velocity (r = -0.386, p = .015 and r = -0.358, p = .025, respectively). Similar negative correlations were also observed at the radius (r = -0.484, p = .006 and r = -0.446, p = .012, respectively). At the exploratory 14% offset site (less distal), we found higher trabecular volumetric BMD (tibia 25%, p = .024; radius 46%, p = .017), trabecular bone volume (tibia 25%, p = .023; radius 46%, p = .017), and trabecular number (tibia 22%, p = .014; radius 30%, p = .010) in T1DN- compared with controls. Both CTX and PINP were lower in participants with TD1 compared with controls. No difference was found in aBMD and appendicular muscle mass. T1DN+ had worse performance in the SPPB compared with T1DN- and control. In summary, neuropathy was associated with cortical porosity and worse performance in physical tests. Our findings suggest that bone structure does not fully explain the rate of fractures in T1D. We conclude that the increase in the risk of fractures in T1D is multifactorial with both skeletal and non-skeletal contributions. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Tatiane Vilaca
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Margaret Paggiosi
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Jennifer S Walsh
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Dinesh Selvarajah
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
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Bai J, Gao Q, Wang C, Dai J. Diabetes mellitus and risk of low-energy fracture: a meta-analysis. Aging Clin Exp Res 2020; 32:2173-2186. [PMID: 31768878 DOI: 10.1007/s40520-019-01417-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/12/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Low-energy fracture risk is significantly increased in diabetes mellitus, the purpose of this article is to systematically evaluate the association between diabetes mellitus and risk for low-energy fracture. METHODS We conducted a systematic literature search of Medline, Embase, Science Citation Index, Wiley Online Library database through January 2019. Pooled relative risks (RR) with corresponding 95% confidence intervals (95% CI) were calculated with random-effects model to assess the strength of association. RESULTS Thirty-seven studies met the inclusion criteria, which included 3,123,382 participants. The pooled RR of any fracture in people with diabetes mellitus was 1.5 (95% CI 1.3-1.8; P < 0.05). The significant association not found in subgroup analysis of prospective design, follow-up period ≥ 10 year (all P > 0.05). The pooled RR of hip fracture in people with diabetes mellitus was 2.0 (95% CI 1.8-2.3; P < 0.05). In addition, subgroup analysis shown higher risk of hip fracture in type 1 diabetes (RR: 5.3). The pooled RR of vertebral fracture with diabetes mellitus was 1.4 (95% CI 0.9-2.2; P = 0.196). Subgroup analysis by type of diabetes showed that the RR of vertebral fracture for patients with unknown-type diabetes was 2.4 (95% CI 1.4-4.0; P < 0.05). Diabetes mellitus was associated with fractures at other sites, and effect estimates was statically significant. CONCLUSIONS Diabetes mellitus is an independent risk factor for low-energy fracture, and this relationship is more pronounced in hip fracture.
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Affiliation(s)
- Jing Bai
- Department of Endocrinology, Cangzhou People's Hospital, No. 7 Qingchi North Avenue, Cangzhou, 061001, China
| | - Qian Gao
- Department of Endocrinology, Cangzhou People's Hospital, No. 7 Qingchi North Avenue, Cangzhou, 061001, China
| | - Chen Wang
- Department of Orthopedics, Cangzhou People's Hospital, No. 7 Qingchi North Avenue, Cangzhou, 061001, China
| | - Jia Dai
- Department of Orthopedics, Cangzhou People's Hospital, No. 7 Qingchi North Avenue, Cangzhou, 061001, China.
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Vilaca T, Schini M, Harnan S, Sutton A, Poku E, Allen IE, Cummings SR, Eastell R. The risk of hip and non-vertebral fractures in type 1 and type 2 diabetes: A systematic review and meta-analysis update. Bone 2020; 137:115457. [PMID: 32480023 DOI: 10.1016/j.bone.2020.115457] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diabetes is associated with increased fracture risk but we do not know what affects this risk. We investigated the risk of hip and non-vertebral fractures in diabetes and whether this risk was affected by age, gender, body mass index, diabetes type and duration, insulin use and diabetic complications. METHODS We selected a previously published review to be updated. MEDLINE, Embase and Cochrane databases were searched up to March 2020. We included observational studies with age and gender-adjusted risk of fractures in adults with diabetes compared to adults without diabetes. We extracted data from published reports that we summarised using random effects model. FINDINGS From the 3140 records identified, 49 were included, 42 in the hip fracture analysis, reporting data from 17,571,738 participants with 319,652 fractures and 17 in the non-vertebral fracture review, reporting data from 2,978,487 participants with 181,228 fractures. We found an increase in the risk of fracture in diabetes both for hip (RR 4.93, 3.06-7.95, in type 1 diabetes and RR1.33, 1.19-1.49, in type 2 diabetes) and for non-vertebral fractures (RR 1.92, 0.92-3.99, in type 1 and RR 1.19, 1,11-1.28 in type 2). At the hip, the risk was higher in the younger population in both type 1 and type 2 diabetes. In those with type 2 diabetes, longer diabetes duration and insulin use was associated with an increased risk. We did not investigate the effect of bone density, falls, anti-diabetic drugs and hypoglycemia. CONCLUSION Diabetes is associated with an increase in both hip and non-vertebral fracture risk.
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Affiliation(s)
- Tatiane Vilaca
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, UK.
| | - Marian Schini
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, UK.
| | - Susan Harnan
- School of Health and Related Research (ScHARR), University of Sheffield, UK.
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, UK.
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, UK.
| | | | - Steven R Cummings
- San Francisco Coordinating Center, Sutter Health, University of California, San Francisco, USA.
| | - Richard Eastell
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, UK.
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Cheng L, Li YY, Hu W, Bai F, Hao HR, Yu WN, Mao XM. Risk of bone fracture associated with sodium–glucose cotransporter-2 inhibitor treatment: A meta-analysis of randomized controlled trials. DIABETES & METABOLISM 2019; 45:436-445. [DOI: 10.1016/j.diabet.2019.01.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 02/07/2023]
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Abstract
OBJECTIVE Diabetes mellitus (DM) is associated with an increased fracture risk; however, the impact of DM and subsequent fracture at different sites and the associations according to patient characteristics remain unknown. DESIGN Meta-analysis DATA SOURCES: The PubMed, EMBASE and Cochrane Library databases were searched from inception to March 2018. ELIGIBILITY CRITERIA We included prospective and retrospective cohort studies on the associations of DM and subsequent fracture risk at different sites. DATA EXTRACTION AND SYNTHESIS Two authors independently extracted data and assessed the study quality. Relative risks (RRs) with 95% CIs were calculated using a random-effects model, and the heterogeneity across the included studies was evaluated using I2 and Q statistics. RESULTS Overall, DM was associated with an increased risk of total (RR: 1.32; 95% CI 1.17 to 1.48; p<0.001), hip (RR: 1.77; 95% CI 1.56 to 2.02; p<0.001), upper arm (RR: 1.47; 95% CI 1.02 to 2.10; p=0.037) and ankle fractures (RR: 1.24; 95% CI 1.10 to 1.40; p<0.001), whereas DM had no significant impact on the incidence of distal forearm (RR: 1.02; 95% CI 0.88 to 1.19; p=0.809) and vertebral fractures (RR: 1.56; 95% CI 0.78 to 3.12; p=0.209). RR ratios suggested that compared with patients with type 2 DM (T2DM), patients with type 1 DM (T1DM) had greater risk of total (RR: 1.24; 95% CI 1.08 to 1.41; p=0.002), hip (RR: 3.43; 95% CI 2.27 to 5.17; p<0.001) and ankle fractures (RR: 1.71; 95% CI 1.06 to 2.78; p=0.029). Although no other significant differences were observed between subgroups, the association of DM with upper arm or ankle, vertebrae and total fracture differed according to sex, study design and country, respectively. CONCLUSIONS Patients with DM had greater risks of total, hip, upper arm and ankle fractures, with T1DM having a more harmful effect than T2DM.
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Affiliation(s)
- Hao Wang
- Department of Endocrinology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Ba
- Department of Endocrinology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Qian Xing
- Department of Endocrinology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jian-Ling Du
- Department of Endocrinology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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The effects of dipeptidyl peptidase-4 inhibitors on bone fracture among patients with type 2 diabetes mellitus: A network meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0187537. [PMID: 29206832 PMCID: PMC5716604 DOI: 10.1371/journal.pone.0187537] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/20/2017] [Indexed: 12/14/2022] Open
Abstract
Aim The association between dipeptidyl peptidase-4 inhibitors (DPP-4is), a class of anti-diabetes, and bone fracture in patients with type 2 diabetes mellitus (T2DM) is unknown. This meta-analysis aimed to systematically evaluate the effects of DPP-4is on bone fracture in T2DM patients. Methods We searched the Cochrane Library, Embase, Medline and ClinicalTrials.gov from inception through April 28th, 2016 to identify randomized controlled trials (RCTs) that compared DPP-4is with placebo or other anti-diabetes in T2DM patients. RCTs lasting more than 12 weeks and having data on bone fracture were included. We conducted random-effects meta-analysis to estimate odds ratios (ORs) and their 95% confidence intervals (CIs), and network meta-analysis (NMA) to supplement direct comparisons. Predictive interval plot and node-splitting method were used to evaluate the heterogeneity and inconsistency for NMA, while the funnel plot was applied to explore publication bias. Besides, study quality was assessed according to Cochrane risk of bias tool. Results We identified 75 RCTs with a total of 70,207 patients and 11 treatments: interventions included 5 DPP-4is (alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin), while controls included placebo and 5 other anti-diabetes (sulfonylureas, glucagon-like peptide-1 receptor agonists, metformin, thiazolidinediones, sodium-glucose co-transporter 2 inhibitors). In the NMA, the risk of fracture for alogliptin tended to decrease when versus placebo (OR, 0.51; 95% CI, 0.29 to 0.88). Besides, aloglitpin had a lower risk compared with linagliptin (OR, 0.45; 95% CI, 0.20 to 0.99) and saxagliption (OR, 0.46; 95%CI, 0.25 to 0.84); the risk was higher with saxagliptin when versus sitagliptin (OR, 1.90; 95% CI, 1.04 to 3.47) and sulfonylureas (OR, 1.98; 95% CI, 1.06 to 3.71). In the direct pairwise meta-analysis, alogliptin was associated with a non-significant tendency to reduction of bone fracture compared with placebo (OR, 0.54; 95% CI, 0.29 to 1.01). Ranking probability analysis indicated alogliptin decreased the risk of bone fracture most with a probability of 76.3%. Conclusion Alogliptin may be associated with a lower risk of bone fracture compared with placebo, linagliptin, or saxagliptin, while other anti-diabetes did not seem to have an association with the risk of bone fracture.
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Adil M, Khan RA, Kalam A, Venkata SK, Kandhare AD, Ghosh P, Sharma M. Effect of anti-diabetic drugs on bone metabolism: Evidence from preclinical and clinical studies. Pharmacol Rep 2017; 69:1328-1340. [DOI: 10.1016/j.pharep.2017.05.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/25/2017] [Accepted: 05/22/2017] [Indexed: 12/18/2022]
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Schwartz AV. Diabetes, bone and glucose-lowering agents: clinical outcomes. Diabetologia 2017; 60:1170-1179. [PMID: 28451714 DOI: 10.1007/s00125-017-4283-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/17/2017] [Indexed: 12/11/2022]
Abstract
Older adults with diabetes are at higher risk of fracture and of complications resulting from a fracture. Hence, fracture risk reduction is an important goal in diabetes management. This review is one of a pair discussing the relationship between diabetes, bone and glucose-lowering agents; an accompanying review is provided in this issue of Diabetologia by Beata Lecka-Czernik (DOI 10.1007/s00125-017-4269-4 ). Specifically, this review discusses the challenges of accurate fracture risk assessment in diabetes. Standard tools for risk assessment can be used to predict fracture but clinicians need to be aware of the tendency for the bone mineral density T-score and the fracture risk assessment tool (FRAX) to underestimate risk in those with diabetes. Diabetes duration, complications and poor glycaemic control are useful clinical markers of increased fracture risk. Glucose-lowering agents may also affect fracture risk, independent of their effects on glycaemic control, as seen with the negative skeletal effects of the thiazolidinediones; in this review, the potential effects of glucose-lowering medications on fracture risk are discussed. Finally, the current understanding of effective fracture prevention in older adults with diabetes is reviewed.
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Affiliation(s)
- Ann V Schwartz
- Department of Epidemiology and Biostatistics, University of California San Francisco, Box 0560, San Francisco, CA, 94143, USA.
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Fan Y, Wei F, Lang Y, Liu Y. Diabetes mellitus and risk of hip fractures: a meta-analysis. Osteoporos Int 2016; 27:219-28. [PMID: 26264604 DOI: 10.1007/s00198-015-3279-7] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 08/05/2015] [Indexed: 01/01/2023]
Abstract
UNLABELLED This meta-analysis revealed that diabetic adults had a twofold greater risk of hip fractures compared with non-diabetic populations, and this association was more pronounced in type 1 diabetes. INTRODUCTION The relationship between diabetes mellitus and risk of hip fracture yielded conflicting results. We conducted a meta-analysis to investigate the association between diabetes mellitus and the risk of hip fractures based on observational studies. METHODS We conducted a systematic literature search of PubMed and Embase databases through May 2015. We selected cohort and case-control studies providing at least age-adjusted risk ratio (RR) and corresponding 95 % confidence intervals (CI) of hip fractures among diabetic and non-diabetic subjects. Moreover, we pooled the female-to-male RR of hip fractures from studies that reported gender-specific risk estimate in a single study. RESULTS Twenty-one studies involving 82,293 hip fracture events among 6,995,272 participants were identified. Diabetes mellitus was associated with an increased risk of hip fractures (RR 2.07; 95 % CI 1.83-2.33) in a random effects model. Subgroup analysis indicated that excess risk of hip fracture was more pronounced in type 1 diabetes (RR 5.76; 95 % CI 3.66-9.07) than that in type 2 diabetes (RR 1.34; 95 % CI 1.19-1.51). The pooled female-to-male RR of hip fractures was 1.09 (95 % CI 0.93-1.28). CONCLUSIONS Individuals with diabetes mellitus have an excessive risk of hip fractures, and this relationship is more pronounced in type 1 diabetes. The association between diabetes and hip fracture risk is similar in men and women.
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Affiliation(s)
- Y Fan
- Institute of Molecular Biology and Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China, 212002
| | - F Wei
- Institute of Molecular Biology and Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China, 212002
| | - Y Lang
- Institute of Molecular Biology and Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China, 212002
| | - Y Liu
- Department of Endocrinology, The Affiliated People's Hospital, Jiangsu University, No. 8 Dianli Road, Zhenjiang, Jiangsu, People's Republic of China, 212002.
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Looker AC, Eberhardt MS, Saydah SH. Diabetes and fracture risk in older U.S. adults. Bone 2016; 82:9-15. [PMID: 25576672 PMCID: PMC4757906 DOI: 10.1016/j.bone.2014.12.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 12/09/2014] [Accepted: 12/12/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We examined the diabetes-fracture relationship by race/ethnicity, including the link between pre-diabetes and fracture. RESEARCH DESIGN AND METHODS We used Medicare- and mortality-linked data for respondents aged 65years and older from the third National Health and Nutrition Examination Survey (NHANES III) and NHANES 1999-2004 for three race/ethnic groups: non-Hispanic whites (NHW), non-Hispanic blacks (NHB), and Mexican Americans (MA). Diabetes was defined as diagnosed diabetes (self-reported) and diabetes status: diagnosed and undiagnosed diabetes (positive diagnosis or hemoglobin A1c (A1C)≥6.5%); pre-diabetes (no diagnosis and A1C between 5.7% and 6.4%); and no diabetes (no diagnosis and A1C<5.7%). Non-skull fractures (n=750) were defined using published algorithms. Hazards ratios (HRs) were calculated using Cox proportional hazards models. RESULTS The diabetes-fracture relationship differed significantly by race/ethnicity (pinteraction<0.05). Compared to those without diagnosed diabetes, the HRs for those with diagnosed diabetes were 2.37 (95% CI 1.49-3.75), 1.87 (95% CI 1.02-3.40), and 1.22 (95% CI 0.93-1.61) for MA, NHB, and NHW, respectively, after adjusting for significant confounders. HRs for diagnosed and undiagnosed diabetes were similar to those for diagnosed diabetes alone. Pre-diabetes was not significantly related to fracture risk, however. Compared to those without diabetes, adjusted HRs for those with pre-diabetes were 1.42 (95% CI 0.72-2.81), and 1.20 (95% CI 0.96-1.51) for MA and NHW, respectively. There were insufficient fracture cases to examine detailed diabetes status in NHB. CONCLUSIONS The diabetes-fracture relationship was stronger in MA and NHB. Pre-diabetes was not significantly associated with higher fracture risk, however.
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Affiliation(s)
- Anne C Looker
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA.
| | - Mark S Eberhardt
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA
| | - Sharon H Saydah
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Abstract
Type 2 diabetes affects an increasing proportion of older adults, the population that is also at elevated risk of fracture. Type 2 diabetes itself increases the risk of fracture, particularly in African-American and Latino populations. In Western countries, overweight and obesity, associated with reduced fracture risk, are highly prevalent in diabetic patients. Studies in East Asian countries that have a lower prevalence of obesity with diabetes may help to disentangle the effects of diabetes and obesity on the skeleton. Type 2 diabetes is also associated with higher bone density, and as a result standard tools for fracture prediction tend to underestimate fracture risk in this population, an important challenge for risk assessment in the clinical setting. Contributing factors to the increased fracture risk in type 2 diabetes include more frequent falls and deficits in diabetic bone, not captured by dual X-ray absorptiometry (DXA), that are as yet not clearly understood. Recent epidemiological studies indicate that poor glycemic control contributes to increased fracture risk although intensive lowering of A1C is not effective in preventing fracture. This article is part of a Special Issue entitled "Bone and diabetes".
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Affiliation(s)
- Ann V Schwartz
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street Box 0560, San Francisco, CA 94143, USA.
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Rathmann W, Kostev K. Fracture risk in patients with newly diagnosed type 2 diabetes: a retrospective database analysis in primary care. J Diabetes Complications 2015; 29:766-70. [PMID: 26074321 DOI: 10.1016/j.jdiacomp.2015.05.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/17/2015] [Accepted: 05/06/2015] [Indexed: 11/16/2022]
Abstract
AIMS It is unclear whether fracture risk is increased in newly diagnosed type 2 diabetes patients. In addition, fracture risk of various sites (hip, spine, upper extremity) was analysed. METHODS The study included 299,104 primary care patients from 1,072 practices who received a first type 2 diabetes diagnosis during the index period (01/2000-12/2013) (Disease Analyser, Germany). Furthermore, 299,104 non-diabetic controls were included after individual matching (1:1) to diabetes cases on age, sex, type of health insurance (private or statutory) and index date (visit at date of first diabetes diagnosis). Cumulative incidence of fractures was estimated for 10 years after index date using product-limit methods. Hazard ratios were calculated using Cox regression models adjusting for comorbidity. RESULTS Cumulative 10-year incidence of any, hip, spine, wrist/hand, forearm, and upper arm/shoulder fractures were 15.4%, 2.9%, 2.6%, 5.1%, 2.3%, and 2.3% in diabetes patients and 13.1%, 2.0%, 2.1%, 4.6%, 2.2%, and 1.7% in controls (log-rank test: all p<0.001, except wrist/hand p=0.56, forearm: p=0.54), respectively. In multivariate Cox regression models, newly diagnosed type 2 diabetes was related to an significantly increased risk of any fracture (adjusted hazard ratio, HR, 95% CI: 1.36, 1.32-1.40), as well as for hip (1.56, 1.45-1.67), spine (1.37, 1.28-1.47), wrist/hand (1.15, 1.03-1.27), forearm (1.12, 1.05-1.20), and upper arm/shoulder (1.61, 1.49-1.74) fractures. CONCLUSIONS Already few years after diabetes diagnosis, type 2 diabetes patients more frequently experienced overall, hip, spine, and upper extremity fractures, respectively. The underlying mechanisms need to be further explored in order to prevent fractures among patients with type 2 diabetes.
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Affiliation(s)
- Wolfgang Rathmann
- German Diabetes Center, Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
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15
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Bello M, Sousa MC, Neto G, Oliveira L, Guerras I, Mendes R, Sousa N. The effect of a long-term, community-based exercise program on bone mineral density in postmenopausal women with pre-diabetes and type 2 diabetes. J Hum Kinet 2014; 43:43-8. [PMID: 25713643 PMCID: PMC4332183 DOI: 10.2478/hukin-2014-0088] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to evaluate the impact of a community-based exercise program on bone mineral density and body composition in postmenopausal women with pre-diabetes and type 2 diabetes. Twenty postmenopausal women (aged 61.3 ± 6.0 years) with pre-diabetes and type 2 diabetes were randomly assigned to a community-based exercise program group (n=10) or a control group (n=10). The community-based exercise program was multicomponent, three days per week for 32 weeks, and included walking, resistance and aquatic exercises. Body composition and bone mineral density were measured pre and post-training by dual X-ray absorptiometry. In the exercise group significant increases were found in the ward's triangle bone mineral density (+7.8%, p=0.043), and in fat-free mass (+2.4%, p=0.018). The findings suggest that regular multicomponent training is effective in preventing osteoporosis and sarcopenia among postmenopausal women with pre-diabetes and type 2 diabetes.
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Affiliation(s)
- Marieni Bello
- Department of Physical Education; Federal University of Piauí, Piauí, Brazil
| | - Maria Cirilo Sousa
- Department of Physical Education; Federal University of Paraíba, Paraíba, Brazil
| | - Gabriel Neto
- Department of Physical Education; Federal University of Paraíba, Paraíba, Brazil
| | - Leonardo Oliveira
- Department of Physical Education; University Mauricio de Nassau – Paraíba, Brazil
| | - Ialuska Guerras
- Federal Institute of Science Education and Technology – Sector Juazeiro do Norte, Brazil
| | - Romeu Mendes
- Research Center in Sport Sciences, Health Sciences and Human Development, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Nelson Sousa
- Research Center in Sport Sciences, Health Sciences and Human Development, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal
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16
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Dai Z, Butler LM, van Dam RM, Ang LW, Yuan JM, Koh WP. Adherence to a vegetable-fruit-soy dietary pattern or the Alternative Healthy Eating Index is associated with lower hip fracture risk among Singapore Chinese. J Nutr 2014; 144:511-8. [PMID: 24572035 PMCID: PMC3952624 DOI: 10.3945/jn.113.187955] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Data on overall dietary pattern and osteoporotic fracture risk from population-based cohorts are limited, especially from Asian populations. This study examined the relation between overall diet and hip fracture risk by using principal components analysis (PCA) to identify dietary pattern specific to the study population and by using the Alternative Healthy Eating Index (AHEI) 2010 to assess dietary quality. The Singapore Chinese Health Study is a prospective population-based cohort that enrolled 63,257 Chinese men and women (including both pre- and postmenopausal women) aged 45-74 y between 1993 and 1998 in Singapore. Habitual diet was assessed by using a validated food-frequency questionnaire. Two dietary patterns, the vegetable-fruit-soy (VFS) pattern and the meat-dim-sum (MDS) pattern, were derived by PCA. Overall dietary quality was assessed according to the AHEI 2010, which was defined a priori for chronic disease prevention. A Cox regression model was applied with adjustment for potential confounders. In both genders, higher scores for the VFS pattern and the AHEI 2010 were associated with lower risk of hip fracture in a dose-dependent manner (all P-trend ≤ 0.008). Compared with the lowest quintile, participants in the highest quintile had a 34% reduction in risk (HR: 0.66; 95% CI: 0.55, 0.78) for the VFS pattern and a 32% reduction in risk (HR: 0.68; 95% CI: 0.58, 0.79) for the AHEI 2010. The MDS pattern score was not associated with hip fracture risk. An Asian diet rich in plant-based foods, namely vegetables, fruit, and legumes such as soy, may reduce the risk of hip fracture.
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Affiliation(s)
- Zhaoli Dai
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore,To whom correspondence should be addressed. E-mail: (Z. Dai), (W.-P. Koh)
| | - Lesley M. Butler
- Division of Cancer Control and Population Sciences and,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Rob M. van Dam
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Li-Wei Ang
- Epidemiology & Disease Control Division, Ministry of Health, Singapore; and
| | - Jian-Min Yuan
- Division of Cancer Control and Population Sciences and,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Woon-Puay Koh
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore,Duke-National University of Singapore Graduate Medical School Singapore, Singapore,To whom correspondence should be addressed. E-mail: (Z. Dai), (W.-P. Koh)
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17
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Hothersall EJ, Livingstone SJ, Looker HC, Ahmed SF, Cleland S, Leese GP, Lindsay RS, McKnight J, Pearson D, Philip S, Wild SH, Colhoun HM. Contemporary risk of hip fracture in type 1 and type 2 diabetes: a national registry study from Scotland. J Bone Miner Res 2014; 29:1054-60. [PMID: 24155126 PMCID: PMC4255308 DOI: 10.1002/jbmr.2118] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/07/2013] [Accepted: 10/18/2013] [Indexed: 12/16/2022]
Abstract
The purpose of this study was to compare contemporary risk of hip fracture in type 1 and type 2 diabetes with the nondiabetic population. Using a national diabetes database, we identified those with type 1 and type 2 diabetes who were aged 20 to 84 years and alive anytime from January 1, 2005 to December 31, 2007. All hospitalized events for hip fracture in 2005 to 2007 for diabetes patients were linked and compared with general population counts. Age- and calendar-year-adjusted incidence rate ratios were calculated by diabetes type and sex. One hundred five hip fractures occurred in 21,033 people (59,585 person-years) with type 1 diabetes; 1421 in 180,841 people (462,120 person-years) with type 2 diabetes; and 11,733 hip fractures over 10,980,599 person-years in the nondiabetic population (3.66 million people). Those with type 1 diabetes had substantially elevated risks of hip fracture compared with the general population incidence risk ratio (IRR) of 3.28 (95% confidence interval [CI] 2.52-4.26) in men and 3.54 (CI 2.75-4.57) in women. The IRR was greater at younger ages, but absolute risk difference was greatest at older ages. In type 2 diabetes, there was no elevation in risk among men (IRR 0.97 [CI 0.92-1.02]) and the increase in risk in women was small (IRR 1.05 [CI 1.01-1.10]). There remains a substantial elevation relative risk of hip fracture in people with type 1 diabetes, but the relative risk is much lower than in earlier studies. In contrast, there is currently little elevation in overall hip fracture risk with type 2 diabetes, but this may mask elevations in risk in particular subgroups of type 2 diabetes patients with different body mass indexes, diabetes duration, or drug exposure.
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Pritchard JM, Giangregorio LM, Atkinson SA, Beattie KA, Inglis D, Ioannidis G, Gerstein H, Punthakee Z, Adachi JD, Papaioannou A. Changes in trabecular bone microarchitecture in postmenopausal women with and without type 2 diabetes: a two year longitudinal study. BMC Musculoskelet Disord 2013; 14:114. [PMID: 23530948 PMCID: PMC3618189 DOI: 10.1186/1471-2474-14-114] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/19/2013] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The risk of experiencing an osteoporotic fracture is greater for adults with type 2 diabetes despite higher than normal bone mineral density (BMD). In addition to BMD, trabecular bone microarchitecture contributes to bone strength, but is not assessed using conventional BMD measurement by dual x-ray absorptiometry (DXA). The aim of this study was to compare two year changes in trabecular bone microarchitecture in women with and without type 2 diabetes. METHODS We used a 1 Tesla magnetic resonance imaging (MRI) scanner to acquire axial images (resolution 195 μm × 195 μm × 1000 μm) of the distal radius. We report the change in the number and size of trabecular bone holes, bone volume fraction (BVTV), trabecular thickness (Tb.Th), number (Tb.N) and separation (Tb.Sp), endosteal area, nodal and branch density for each group. Lumbar spine and proximal femur BMD were measured with DXA (Hologic, Discovery QDR4500A) at baseline and follow-up. Using a multivariable linear regression model, we evaluated whether the percent change in the trabecular bone microarchitecture variables differed between women with and without type 2 diabetes. RESULTS Of the 54 participants at baseline with valid MRI image sets, 37 participants (baseline mean [SD] age, 70.8 [4.4] years) returned for follow-up assessment after 25.4 [1.9] months. Lumbar spine BMD was greater for women with diabetes compared to without diabetes at both baseline and follow-up. After adjustment for ethnicity, women with diabetes had a higher percent increase in number of trabecular bone holes compared to controls (10[1] % versus -7 [2]%, p=0.010), however results were no longer significant after adjustment for multiple comparisons (p=0.090). There were no differences in the change in other trabecular bone microarchitecture variables between groups. CONCLUSION There were no differences in percent change in trabecular bone microarchitecture variables over two years in women with type 2 diabetes compared to women without diabetes. This study provides feasibility data, which will inform future trials assessing change in trabecular bone microarchitecture in women with type 2 diabetes. Larger studies using higher resolution imaging modalities that can assess change in trabecular and cortical bone compartments in women with type 2 diabetes are needed.
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Affiliation(s)
- Janet M Pritchard
- Faculty of Health Sciences, McMaster University, 1280 Main St West, Hamilton, ON L8S 4K1, Canada
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Stephanie A Atkinson
- Department of Pediatrics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4K1, Canada
| | - Karen A Beattie
- Department of Medicine, McMaster University, Charlton Medical Centre, 501-25 Charlton Ave E, Hamilton, ON L8N 1Y2, Canada
| | - Dean Inglis
- Department of Civil Engineering, McMaster University, 1280 Main St West, Hamilton, ON L8S 4K1, Canada
| | - George Ioannidis
- Department of Medicine, McMaster University, Charlton Medical Centre, 501-25 Charlton Ave E, Hamilton, ON L8N 1Y2, Canada
| | - Hertzel Gerstein
- Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4K1, Canada
| | - Zubin Punthakee
- Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4K1, Canada
| | - Jonathan D Adachi
- Department of Medicine, McMaster University, Charlton Medical Centre, 501-25 Charlton Ave E, Hamilton, ON L8N 1Y2, Canada
| | - Alexandra Papaioannou
- Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4K1, Canada
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