Diabetes And Osteoporosis

People diagnosed with type 1 and 2 diabetes are at risk of bone fractures and bone fragility. This is similar to osteoporosis which is usually associated with a decreased bone mass and risk of bone fracture. Bone fractures can impact the quality of your life, primarily through disability and increased risk of different diseases due to associated hospitalization from fractures. 

That's why it's vital to understand how diabetes and your bone health are related, their signs and symptoms, treatment, and prevention measures. Keep reading to learn more. 

What is diabetes? 

Diabetes is a condition associated with the pancreas's low or no insulin production in type 1 diabetes or the body's inability to respond to insulin in type 2. Since insulin regulates blood sugar, lack of enough insulin or the failure to respond to it raises your blood sugar — a condition referred to as hyperglycemia. Inability to manage diabetes might lead to severe damage, especially to the blood vessels and nerves. 

There are two common types of diabetes: 

Type 1 diabetes

With type 1 diabetes, the body produces little or no insulin. It typically starts in childhood.

Type 2 diabetes

With type 2 diabetes, the pancreas may produce sufficient insulin, but the body doesn't respond to it as required. It's common in people who're inactive, overweight, or older. 

What is osteoporosis?

Osteoporosis is a bone disease that develops from decreasing bone mineral density and mass. It reduces bone strength, increasing the risk of bone fracture. 

Different factors can increase the risk of osteoporosis, including: 

• Having a small frame or being thin

• Low BMI

• Being born in a family with a history of osteoporosis 

• If you're a woman experiencing early menopause, failure to have menopause, and being postmenstrual 

• Use of certain medications like glucocorticoids

• Low calcium intake

• Prolonged immobilization

• Excessive alcohol consumption

• Smoking

How are diabetes and osteoporosis related? 

Like in osteoporosis, increased bone fracture risk is common in people with type 1 and 2 diabetes. However, not all people with diabetes have low bone mineral density. Unlike postmenopausal and senile osteoporosis, deterioration of bone strength in diabetes is secondary to increased cortical porosity that is not explained by a loss of trabecular bone mass, hence the term diabetic bone disease. 

Here is a breakdown of how both types of diabetes contribute to osteoporosis.  

The relationship between type 1 diabetes and bones

Type 1 diabetes is usually associated with low bone mineral density. It leads to decreased bone mass, as the disease usually starts in childhood or adolescence and affects growing bones, which results in failure to acquire bone during growth. 

Hyperglycemia seen in type 1 diabetes may lead to increased calcium loss in the urine, thus inhibiting bone formation as markers of bone turnover are usually low. Subsequently, inhibited bone formation can lead to fragile bones. 

A study conducted in Iowa¹ involving 32,089 postmenstrual women revealed that postmenstrual women with type 1 diabetes are at a higher risk of hip fractures than those without diabetes. 

The relationship between type 2 diabetes and bones

Contrary to studies associated with type 1 diabetes and bones, studies of type 2 diabetes have shown that the bone mineral density is average or higher than those without diabetes. However, the increased risk for bone fractures remains. For instance, in a study² involving 5,931 people with type 2 diabetes aged 55 years and more, an increased bone mineral density is seen in those with non-insulin dependence.

Even though non-insulin-dependent women with type 2 diabetes had higher bone mineral density, more studies³ have proven that they are at higher risk of hip and proximal humerus fractures, especially postmenstrual women. But this finding was not repeated for men. 

The increased chances of fractures among these women may be associated with the higher incidence of falls associated with diabetes-related complications, such as retinopathy and neuropathy. This can also be due to increased bone porosity, which reduces bone strength that the typical DXA scan cannot detect.

Does diabetes cause osteoporosis or low bone density? 

There is a complex relationship between diabetes and bone health. It is still unclear how they interact with one another. However, scientists believe insulin deficiency is the primary cause of osteoporosis in people with type 1 diabetes.

Insulin works as an anabolic agent. Its deficiency can negatively affect various bone properties, such as bone mineralization surface areas, strength, and osteoblast activities. 

More and more studies demonstrate intricate play between insulin metabolism and skeletal energy metabolism. Thus, insulin therapy does not necessarily reverse changes seen in the bone secondary to diabetes, and some antidiabetic agents may have detrimental effects on bone health. 

Another important hormone is insulin-like growth factor-1 (IGF-1). IGF-1 is a major mediator of hormone-stimulated growth and is important for the proliferation and differentiation of osteoblasts, which are the main cells responsible for building bone. Thus, loss of IGF-1 signaling in type 1 diabetes plays a crucial role in the development of bone disease in this population.

Many studies show that the insulin deficiency associated with type 1 diabetes explains the bone disease that can ultimately cause increased fracture risk. However, people with type 2 diabetes should not have a high fracture risk since this type of diabetes is hallmarked by insulin resistance rather than insulin deficiency. 

The current evidence suggests that constant high blood sugar levels or hyperglycemia can affect blood flow to the bones on a microscopic level. This leads to less osteoblast and more adipocyte (fat cell) production affecting the strength of the bone, which can be demonstrated by cortical bone defects.

In chronic hyperglycemia, excess glucose interacts with tissue proteins and free amino acids to form advanced glycation (AGE) end products. 

According to a study,⁴ the accumulation of AGE products alters collagen structure and impacts osteoblast and osteoclast function. This increases bone marrow adiposity, releases inflammatory cytokines, and alters osteocyte number and function, contributing to reduced bone quality and associated diabetic bone disease and increased fracture risk.

Another study⁵ shows that glycosuria can lead to hypercalciuria, which ultimately decreases calcium levels in the body. Glycosuria refers to the excess glucose being excreted in urine secondary to hyperglycemia, while hypercalciuria is the excessive calcium levels in urine. This leads to less calcium availability for bone-building, wherein the body sometimes taps into the bone calcium reserves just to stabilize blood calcium levels. 

Additionally, several diabetes-related complications like retinopathy and neuropathy are independently associated with reduced bone mineral density. They can themselves increase the risk for falls leading to an even more increased risk of bone fractures.

What are the other causes of osteoporosis? 

Low bone mineral density is the hallmark of osteoporosis. As bone density decreases, the bones become thinner and more fragile. In some cases, changes in the bone structure can lead to fractures. 

There are several risk factors related to osteoporosis. Some of these might change while others are static. These include:

Gender

Women are more likely to develop osteoporosis than men as they reach a lower peak bone mass and have increased declines secondary to aging. Men are still at risk, but it's more prevalent for men at 70 years. 

Age 

As you age, you start experiencing bone loss more than when you're younger, which is especially prominent in men. As people age, new bone growth is much slower. Therefore, your bones weaken and are at a higher risk of osteoporosis as time goes by. 

Body size

Loss of bone mass is accelerated in men and women with lower body mass index (BMI). A BMI of less than 24kg/m² has been associated with increased loss of bone mineral density.

People of a particular race 

White and Asian adults are at a higher risk of osteoporosis than Hispanics and African Americans. 

Hormonal changes 

Low levels of particular hormones can increase the possibility of osteoporosis. Examples of hormonal changes that can result in osteoporosis are as follows: 

• Low estrogen levels for postmenopausal women

• Low estrogen levels from the abnormal absence of menstrual periods in premenopausal women due to extreme physical activities or hormonal disorders 

• Low testosterone levels in men in the context of hypogonadism

Diet 

A diet low in vitamin D and calcium puts you at risk of osteoporosis and fractures, especially if it begins in childhood. Poor protein intake can also increase the possibility of osteoporosis. 

Medical conditions 

Some medical conditions increase the risk of osteoporosis. This includes hormonal diseases, endocrine diseases, rheumatoid arthritis, anorexia nervosa, and HIV/AIDS. 

Certain medication 

Long-term dependency on particular medications can increase the risk of osteoporosis or insufficiency fractures. These drugs include: 

• Glucocorticoids and adrenocorticotropic hormones to treat conditions such as rheumatoid arthritis and asthma

• Antiepileptic medicines that treat seizures

• Cancer medication used to treat prostate and breast cancer 

• Proton pump inhibitors, which lower stomach acid

• Thiazolidinediones, which treat type 2 diabetes 

• Selective serotonin reuptake inhibitors, which treat anxiety and depression 

Lifestyle 

Maintaining a healthy lifestyle helps keep your bones stronger. However, certain lifestyles can contribute to bone loss, including: 

• Prolonged periods of inactivity or low physical activities

• Chronic or heavy alcohol drinking 

• Smoking 

Signs and symptoms of osteoporosis 

Osteoporosis has no apparent signs and symptoms. Many people don't realize that they have the condition until they fall or bump, break their bones, or a fracture occurs spontaneously. However, specific signs and symptoms at early and late stages show that you have osteoporosis. 

Here's a closer look at the symptoms of osteoporosis in its early and late stages. 

Symptoms of osteoporosis at its early stages 

It's rare to find early signs of bone loss. Most people know that they have weak bones when they break their wrist, hip, or other bone. However, the following symptoms indicate a potential bone loss: 

Back pain

People with osteoporosis are more likely to present with back pain after vertebral fractures — an injury to one of the bones in your spine.

Kyphosis

Multiple thoracic compression fractures can cause dorsal kyphosis and associated cervical lordosis called dowager’s hump. It refers to a curving of the spine in your upper back, usually resulting in the person appearing to have a rounded or hunched upper back.

Shortness of breath/early satiety

People with osteoporosis can experience shortness of breath due to reduced intrathoracic volume and early satiety secondary to compression of the abdominal cavity.

It's rare to detect osteoporosis at the early stages unless you’re being screened for it per USPSTF guidance. The above symptoms should help you determine whether you have this condition, especially if you have a family history of osteoporosis.  

Symptoms of osteoporosis at the later stages 

As the bone deteriorates, you will start experiencing apparent symptoms associated with osteoporosis. These symptoms include: 

Height loss

Spinal compression fractures can make you shorter. This is one of the most evident osteoporosis symptoms.  

Fall fractures

Fractures are common signs of fragile bones, especially from minor movements, such as misstepping a curb or coughing or sneezing. 

Stooped fracture or posture

Compressions on the vertebrae can also cause slight curving of your upper back. This is referred to as kyphosis and can cause back and neck pain. 

Complications associated with osteoporosis 

Fractures are the most common complication associated with osteoporosis. They can occur in the spine, wrist, hip, or sacrum, resulting in significant morbidity. 

One of the most severe complications of this condition is vertebral compression fracture. This fracture type can occur when carrying heavy loads, experiencing minor falls, or sometimes without an identifiable cause.

Typical vertebrae are stacked on each other. Osteoporosis weakens these vertebrae, making them appear as hollow boxes. Other complications associated with vertebral compression fracture include: 

• Back pain might start gradually and end up severe

• A hunch in the upper back at the point where the vertebrae have partially collapsed 

• Instability and loss of mobility while performing certain activities 

• Cardiovascular and respiratory complications when multiple fractures shorten the torso and compress the abdomen 

• Rare neurological injury

• Loss of self-esteem, mood changes, and loss of independence

Treatment of bone disease related to diabetes 

Treating the underlying condition (diabetes) will help you deal with diabetes-related bone disease. There are different medications used to treat diabetes. These drugs are taken orally or through injection. Here's a breakdown of how to treat type 1 and 2 diabetes.  

Type 1 diabetes

The primary treatment for type 1 diabetes is insulin. It's used to replace the insulin that the body cannot produce. People with type 1 diabetes are given a mixture of four types of insulin based on their onset and duration of action. These four types of insulin are as follows: 

• Rapid-acting insulin which works within fifteen minutes and lasts for three to four hours 

• Short-acting insulin which works within thirty minutes and lasts for six to eight hours 

• Intermediate-acting insulin works within one to two hours and lasts twelve to eighteen hours 

• Long-lasting insulin works within a few hours and lasts for twenty-four hours or more. 

Type 2 diabetes

Type 2 diabetes is usually treated through diet or exercise. However, if these two options don't lower your sugar, you’ll be prescribed one or more of the following medications before ultimately starting insulin therapy: 

Alpha-glucosidase inhibitors

These drugs lower blood glucose levels by altering intestinal absorption of carbohydrates. 

Biguanides

These drugs reduce the amount of glucose made by your liver and increase the body's responsiveness to insulin.

DPP-4 inhibitors

These drugs increase insulin production and decrease the liver's production of glucose. 

Glucagon-like peptide 1 agonists

These drugs increase glucose-dependent insulin secretion from beta cells and help to ensure an appropriate insulin response following ingestion of a meal. 

Meglitinides

These drugs stimulate the pancreas to release more insulin. 

SGLT2 Inhibitors

These drugs release more glucose into your urine. 

Sulfonylureas

These drugs stimulate the pancreas to release more insulin. 

Thiazolidinediones

These drugs increase insulin responsiveness and may also improve insulin secretion by preserving pancreatic beta-cell function.

Your doctor might recommend more than one of these drugs. They might also recommend insulin to some people with type 2 diabetes.  

Treatment of osteoporosis

Osteoporosis treatment includes medications that will help build your bone mass or stop bones' absorption. Some of the drugs used to treat osteoporosis are as follows: 

• Bisphosphonates

• Teriparatide

• Denosumab

• Calcitonin 

• Estrogen in rare cases

You can also consider kyphoplasty as your treatment for complications resulting from vertebral fractures. This is a surgical treatment for fractures that involves the insertion of small incisions into collapsed vertebrae to restore your height and spine's function. These balloons are replaced by cement to strengthen your bones.

Can you prevent bone disease related to diabetes? 

To an extent, yes. If the underlying diabetes is well controlled, the resultant bone disease should be minimal. Here's a breakdown of what you should do: 

How to prevent diabetes

Although there are numerous studies ongoing for prevention or slowing down the progression of type 1 diabetes, no options are currently available. However, it's easier to control or prevent type 2 diabetes, but factors like age and genes are not under your control. 

Many other diabetes risk factors are controllable by making simple diet adjustments and adhering to a fitness routine. Anyone who's diagnosed with prediabetes should consider the following to delay or prevent the development of type 2 diabetes: 

• Engage in aerobic exercises, such as cycling and walking for at least 150 minutes every week

• Cut down the consumption of trans or saturated fats and refined carbohydrates

• Eat more vegetables, whole grains, and fruits 

• Eat smaller portions 

• Try to lose at least 7% of your bodyweight if you're obese or overweight. 

How to prevent osteoporosis

You can adopt different measures to manage osteoporosis. For instance, adding vitamin D supplements to your diet can help your body absorb calcium. 

Engaging in moderate exercise can also keep your body strong. Practice balance-training exercises such as tai chi and yoga to better your balance and avoid the risks of falls and fractures. 

You can also improve your eyesight or use a walker or cane to prevent slipping or falling while walking. 

When should you see a doctor?

If you're at risk of bone disease due to diabetes, it's best to ask your doctor for screening. This will help you use relevant prevention and treatment measures before the condition worsens. This is crucial even for women who're not as old as 65 years or 70 for men. You can still avoid fractures by working with your healthcare provider. 

The lowdown

Unlike osteoporosis, there is enough evidence proving that diabetes is associated with an increased risk of bone fractures. However, more research still needs to be done to determine what causes this condition and how to best treat and prevent it. 

It's vital for anyone with diabetes to seek early screening for bone disease, especially if they come from a family with a history of osteoporosis. This will help curb the complications associated with bone fractures, leading to a fully active and fulfilling life.