Although osteoporosis is the most prevalent metabolic bone disease in the United States, its impact in people with diabetes is not often considered. Routine screening or initiation of preventive medications for osteoporosis in all patients with type-1 or type-2 diabetes is not recommended at this time.
However, all patients with diabetes, and particularly those with fractures, should be given general recommendations regarding adequate dietary calcium intake, vitamin D, regular exercise, and avoidance of other potential risk factors like alcohol and smoking. Consideration of bone density evaluation using the DEXA scan should be part of the fracture evaluation, and respective preventive or therapeutic interventions should be applied.
When we think about long term complications of diabetes, osteoporosis is not one that comes to mind right away. The definition of osteoporosis is: a bone condition defined by low bone mass, increased fragility, decreased bone quality, and an increased risk for bone fracture. It is the most prevalent metabolic bone disease in the United States. Low bone mass conditions increase fracture risks, with osteoporosis having the greater impact.
Osteoporosis is expensive in terms of national spending and because of the cost of fractures due to the disease. The National Osteoporosis Foundation reports that this amount is $13.8 billion per year, and that is expected to double over the next 25 years.
Osteoporosis is not symptomatic until there is a fracture.
Type-2 diabetes had previously been thought to provide bone protection because it is associated with normal to increased BMD, but this information was not based on prospective controlled large trials. Risk factors are higher for type-2 diabetes than for the general population because of peripheral neuropathy, possible hypoglycemia, nocturia, and visual impairment. Because many type-2 diabetics are over weight and sedentary, coordination and balance factors that protect people from falls are impaired or not present.
Thus patients with a larger body size and relatively high bone mass may have a higher fracture rate. Bone quality changes may also be affected by microvascular events common to diabetes. The Study of Osteoporotic Fractures confirmed that women with type-2 diabetes experience higher fracture rates in regions of the hip, humerus, and foot than do non-diabetic women.
Bone loss has also been observed to be greater in patients with poorly controlled diabetes than in those whose diabetes was in tight control. Gestational diabetes has not been reported to be associated with bone loss in prospective trials. However, a small study involving Hispanic women with gestational diabetes noted that 40% of the 20 enrolled subjects had CXA-detected bone loss when three months postpartum. Advanced age and higher oral glucose tolerance test values during pregnancy may be associated with increased bone loss. Larger prospective studies are needed to confirm these findings.