Did you know that people with diabetes are at greater risk for bone fractures? A fracture is defined as any broken bone. Bones break when outside force(s) are applied which are greater than the strength of the bone. Bones can break crosswise, lengthwise or in pieces.(1) We will explore the results of five studies linking diabetes with an increased risk for fractures. Questions to ask your physician about fracture prevention are also included to help you stay healthy.

link between fractures and diabetesFive studies linking diabetes and fractures:

1. The Prospective Study of Diabetes and Risk of Hip Fractures (The Nurses’ Health Study) was published in 2006. This study followed 109,983 women between the ages of 34-59 with and without diabetes for approximately 20 years. People with diabetes (type 1 or type 2) were associated with having an increased risk for hip fractures. Fracture prevention strategies for women with diabetes were recommended.(2)  

2. The Diabetes and Risk of Fracture-Related Hospitalization: The Atherosclerosis Risk in Communities Study was published in 2012. (3,4) This study reviewed fracture related hospitalizations at four large community hospitals and included; leg, ankle, arm, ribs, spine, skull and face, hip, hand, shoulder, wrist and foot fractures. There were 1,078 incidents of fracture related hospitalizations examined during a median of 20 years follow-up. The study involved 15,140 subjects between the ages of 45-64 years. Fractures that did not result in an inpatient hospitalization were excluded in the numbers.  Subjects with diagnosed diabetes had a significantly increased risk of having fractures. People with diabetes who needed insulin therapy and those with hemoglobin A1c levels equal or higher than 8 percent were also at a higher risk of fractures. These risks were not associated with using oral diabetes medications. The fracture risk of people with undiagnosed diabetes at the baseline visit was approximately the same as those without diabetes.

Recommendations made by the research team included assessing all patients with diabetes for fracture risk and encouraging prevention tactics for people that could benefit from them. People with A1c levels equal or higher than 8 percent, may especially benefit from prevention efforts.

3. In 2010 David Paglia and others reviewed an extensive amount of research on diabetes and fracture healing at the cellular level. His team concluded that people with diabetes that have had unintentional skeletal trauma or those electing orthopedic surgery are at risk for delayed healing of fractured bones. Conclusions: Blood glucose control improves outcomes in fracture healing.(5)

4. A 2010 study of more than 19,000 men and women concluded that women older than 65 years of age with type 2 diabetes were 70 percent more likely to have fractures of the upper extremity and distal lower extremity if they took a thiazolidinedione (TZD) diabetes medication for more than one year.(6)  Rosiglitazone (Avandia) and pioglitazone (Actos) are the two medications that belong to this class of medication available in the United States.(7). The senior author of the study recommended having routine screening for bone loss, and therapy to prevent bone loss may be needed when a patient is given a TZD medication.(6)

5. Research published in 2013 reviewed over 11,000 adults with type 1 diabetes entered into the United States Renal Data System. Findings included: men with type 1 diabetes in need of kidney transplantation who had both a kidney and pancreas transplantation, had a reduced fracture risk compared to those with only a kidney transplant. In both men and women, a body mass index (BMI) less than 18.5 kg/m2, a fracture that occurred prior to the transplant and dialysis increased fracture risk.(8) Pancreas-kidney transplantation is associated with reduced fracture risk compared to kidney alone transplantation in men with type 1 diabetes.

What should someone with diabetes ask their doctor about bone health and the prevention of fractures?
As you can see from the studies mentioned, fractures can be a real problem for people with either type 1 or type 2 diabetes.

Discussions with your doctor and medical team might include the following:
  1. What kinds of screening should I have to prevent fractures?(9) I heard a bone mineral density test is one way to measure bone health.(10)  Should I have one and how often should this be repeated? 
  2. Is my hemoglobin A1c high? If it is, what steps can I take to reduce to help with my health, including preventing fractures?(9,11) 
  3. Do I take any medications that increase my risk for fractures?(9) If so, are there any substitutions that can be made to decrease this risk? 
  4. Should I see my dietitian to make sure I am consuming adequate amounts of calcium?(9) 
  5. Are my vitamin D levels adequate?(9) If not should I be taking prescription Vitamin D? 
  6. Should I be on a medication specifically to help prevent fractures?(9) 
  7. What exercise should I be doing to help prevent fractures?(12)
  8. Should I avoid doing any types of exercise that increase my risks of breaking bones?
  9. Is there any special shoes or clothing I need to exercise?

Visit the National Instituite of Arthritis and Musculoskeletal and Skin Diseases website for more information on osteoporosis management strategies to prevent fractures.