Vijay Shivaswamy, Lynn Mack and Jennifer Larsen
All types of diabetes increase risk for osteoporosis and fracture due to multiple factors. Hyperglycemia itself may play a role, but frequent hypoglycemia, falls, hypogonadism, vitamin D deficiency, body mass index (BMI), and advanced complications may play an even larger role. Very low BMI in type 1 diabetes and elevated BMI in youth with type 2 diabetes can increase fracture risk, as well as visceral obesity in postmenopausal women. Those with advanced complications, such as peripheral and autonomic neuropathy, visual impairment, renal failure, and vascular disease are also at greater risk, in part due to greater risk for falls. Many medications can contribute to bone loss, but the thiazolidinediones are the only diabetes medications known to have a direct impact on bone mass, particularly in women. After transplant, immunosuppressant medications also contribute to fracture risk.
Bone density screening in patients with diabetes should be initiated with any known risk factors, such as at onset of menopause or other types of hypogonadism, or if part of a known high-risk sub-group, such as cystic fibrosis related diabetes or organ transplant recipients. Vitamin D screening should be performed in those with borderline low calcium, lactose intolerance, celiac sprue, post-menopause, or history of fracture. Therapy of osteoporosis should be tailored to the patient, while optimizing vitamin D concentration, and with special attention to renal function.
In summary, decreased bone density and fractures are more common in diabetes due to multiple factors that should be systematically considered and addressed. Bone density screening should be considered part of health care maintenance in many sub-groups of diabetes patients even though it has not yet been incorporated into the usual care guidelines for all diabetes patients.