Diagnosis and management of bone fragility in diabetes: an emerging challenge

Qing'e Pill rectifies bone homeostasis imbalance in diabetic osteoporosis via the AGE/RAGE pathway: A network pharmacology analysis and multi-omics validation

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetic osteoporosis (DOP), a metabolic disorder arising from diabetes mellitus, results in a hyperglycemic state that impairs bone microstructure, strength, and quality, thereby increasing the risk of fractures and complicating treatment and rehabilitation. Qing'e Pill(QEP), first recorded in the Song Dynasty's Heji Ju Fang, is renowned as an effective formula for tonifying the kidneys and strengthening bones. Its potential therapeutic mechanisms for treating DOP remain to be explored.

AIM OF THE STUDY

This study aimed to elucidate the therapeutic mechanism of QEP, a Chinese herbal medicine compound, in the treatment of DOP by integrating network pharmacology and laboratory analyses.

MATERIALS AND METHODS

Gene targets associated with DOP were identified utilizing gene databases (GeneCards, TTD, OMIM). The active ingredients of QEP were characterized via HPLC analysis. The therapeutic potential of QEP was assessed in a rat model of DOP by monitoring blood glucose levels, employing Micro-CT imaging, and conducting histological staining. In vitro experiments were performed to confirm QEP's ability to promote bone formation. Additionally, its angiogenic potential was evaluated using scratch, migration, and tube formation assays.

RESULTS

QEP was observed to stimulate osteogenesis and angiogenesis in vitro, modulate the AGE/RAGE signaling pathway, and foster anti-inflammatory osteogenesis. Micro-CT analysis demonstrated significant enhancements in bone density and microstructure following QEP treatment.

CONCLUSION

QEP enhance osteogenesis and angiogenesis via the AGE/RAGE signaling pathway, offering anti-inflammatory, hypoglycemic, and anti-osteoporotic effects. These results support the potential clinical application of QEP in managing diabetic osteoporosis.

Bone microstructure and TBS in diabetes: what have we learned? A narrative review

Diabetes is associated with an increased risk of fracture. Areal bone mineral density (aBMD), the most reliable indicator of fracture risk in healthy adults, is low in patients with type 1 diabetes mellitus but normal or high in patients with type 2 diabetes mellitus. Most trabecular and cortical parameters measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) are lower in type 1 diabetes and higher in type 2 diabetes, in parallel with aBMD. In contrast, lumbar spine trabecular bone score (TBS) has been reported to be lower in women with both type 1 and type 2 diabetes. The discordance between improved bone microstructure and degraded TBS reflects the effect of central obesity (currently the subject of a revision to the TBS algorithm). Meanwhile, evidence supports use of TBS in conjunction with aBMD and/or FRAX for improved fracture prediction in patients with type T2D. This position paper, on behalf of the Bone and Diabetes Working Group of the International Osteoporosis Foundation, summarizes alterations in bone microarchitecture measured by HR-pQCT in diabetes. It also addresses the technical and clinical considerations of the trabecular bone score, particularly discussing the significance of this measurement in individuals with diabetes and the influence of abdominal fat.

Prevalence and risk factors for osteoporosis in type 1 diabetes-results from an observational study

The prevalence of osteoporosis in individuals with type 1 diabetes (T1D) was investigated. Based on IOF/ADA recommendations, 36% had indications for anti-osteoporotic therapy. We propose that postmenopausal women and men with T1D and age > 50 years are screened for osteoporosis.

PURPOSE

Type 1 diabetes is associated with an increased fracture risk and a lowering of the threshold for osteoporosis treatment has been recommended to be increased from a bone mineral density of a T-score ≤ - 2.5 to a T-score ≤ - 2.0. In this study, we aimed to investigate the prevalence and risk factors for osteoporosis in type 1 diabetes using the classic diagnostic criteria defined by WHO and the novel T-score cutoff of - 2.0 proposed by the ADA.

METHODS

In a cross-sectional study, data were collected from the type 1 diabetes clinic at Steno Diabetes Center Aarhus, Aarhus University Hospital, where active attenders in the clinic were offered screening for osteoporosis using DXA of the lumbar spine and hip in the time period 2020-2022.

RESULTS

A total of 764 individuals with type 1 diabetes had a DXA and of these, 25.5% had osteoporosis based on a vertebral fracture or T-score ≤ - 2.5, and 36% met ADA-treatment criteria with a vertebral fracture or T-score ≤ - 2.0. In multivariate analysis increasing age (OR = 1.3, 95% CI 1.0; 1.7) and a family history of osteoporosis (OR = 1.9, 95% CI 1.2; 3.0) were associated with an increased risk of osteoporosis, whereas an increase in BMI was associated with a decreased risk of osteoporosis (OR = 0.87, 95% CI 0.82; 0.92).

CONCLUSION

The present study finds that a high proportion of individuals with type 1 diabetes have osteoporosis, and an even higher proportion meet the treatment criteria proposed by the ADA, and thus, early detection and treatment of osteoporosis may reduce the apparent increased fracture risk in type 1 diabetes.

Progress in research on osteoporosis secondary to SARS-CoV-2 infection

The World Health Organization has declared that COVID-19 no longer constitutes a "public health emergency of international concern," yet the long-term impact of SARS-CoV-2 infection on bone health continues to pose new challenges for global public health. In recent years, numerous animal model and clinical studies have revealed that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can lead to secondary osteoporosis. The mechanisms involved are related to the virus's direct effects on bone tissue, dysregulation of the body's inflammatory response, hypoxia, noncoding RNA imbalance, and metabolic abnormalities. Although these studies have unveiled the connection between SARS-CoV-2 infection and osteoporosis, current research is not comprehensive and in depth. Future studies are needed to evaluate the long-term effects of SARS-CoV-2 on bone density and metabolism, elucidate the specific mechanisms of pathogenesis, and explore potential interventions. This review aims to collate existing research literature on SARS-CoV-2 infection-induced secondary osteoporosis, summarize the underlying mechanisms, and provide direction for future research.

Biases in the performance of FRAX without BMD in predicting fracture risk in a multiethnic population with diabetes: the Diabetes and Aging Study

Fracture risk calculators, such as the Fracture Risk Assessment Tool (FRAX), calculate the risk of major osteoporotic fracture (MOF) and hip fracture but do not account for the excess risk of fracture in people with diabetes. We examined the predictive performance of FRAX without BMD in ethnically diverse, older patients with diabetes. Patients included were between ages 65 and 89 from the Kaiser Permanente Northern California Diabetes Registry and not already taking osteoporosis medications. Race and ethnicity were self-identified. We calculated FRAX without BMD based on baseline characteristics and assessed how well FRAX predicted MOF and hip fracture over follow-up. Predictive performance was based on measures of discrimination (area under the receiver operator curve, AUC) and calibration (observed-to-predicted ratio, O/P). We identified 96 914 patients (47.0% female), of whom 5383 (5.6%) and 1767 (1.8%) had MOF and hip fracture, respectively, over a mean follow-up of 4.3 yr. The AUC for MOF and hip fracture were 0.72 and 0.77, respectively. FRAX mildly underestimated MOF and hip fracture rates (O/P 1.2 for both) overall. Discrimination was similar by race and ethnicity and diabetes duration but was worse in those over age 75 (AUC < 0.7). In some groups, there were substantial calibration errors, such as Hispanic women (O/P: 1.8 and 1.5), Black men (O/P: 1.5 and 1.8), those with duration of diabetes ≥20 yr (O/P: 1.6 and 1.5), and those over the age of 80 (O/P: 1.4 and 1.2) for MOF and hip fracture, respectively. While the discriminatory performance of FRAX without BMD was good overall in patients with diabetes, it underestimated risk in Hispanic women, Black men, those with long duration of diabetes, and in the oldest patients with diabetes. These algorithmic biases suggest that diabetes-specific tools may be needed to stratify fracture risk in patients with diabetes.

Artificial intelligence tools in supporting healthcare professionals for tailored patient care

Artificial intelligence (AI) tools to support clinicians in providing patient-centered care can contribute to patient empowerment and care efficiency. We aimed to draft potential AI tools for tailored patient support corresponding to patients' needs and assess clinicians' perceptions about the usefulness of those AI tools. To define patients' issues, we analyzed 528,199 patient messages of 11,123 patients with diabetes by harnessing natural language processing and AI. Applying multiple prompt-engineering techniques, we drafted a series of AI tools, and five endocrinologists evaluated them for perceived usefulness and risk. Patient education and administrative support for timely and streamlined interaction were perceived as highly useful, yet deeper integration of AI tools into patient data was perceived as risky. This study proposes assorted AI applications as clinical assistance tailored to patients' needs substantiated by clinicians' evaluations. Findings could offer essential ramifications for developing potential AI tools for precision patient care for diabetes and beyond.

Periprosthetic Fracture After Cementless Revision Total Hip Arthroplasty with a Tapered, Fluted Monobloc Stem: A Retrospective Long-Term Analysis of 121 Cases

Background: The use of tapered monobloc stems in revision total hip arthroplasty (RTHA) has shown excellent results, with low implant-dependent failures due to aseptic loosening. Infection is one of the main failure reasons, but further problems, like periprosthetic fractures (PPFs), may endanger the function and duration of the implant in the long run. Methods: A consecutive series of 121 cases after femoral RTHA with a monobloc device was retrospectively investigated, and a Kaplan-Meier analysis was performed. The mean follow-up was 13.0 (range: 0.8-23.8) years. Results: PPF occurred in six patients during follow-up. The cumulative risk for PPF was 5.2% (95% CI: 1.1-9.4%) after 23.8 years. Female gender was associated with a significantly higher risk compared to male gender (9.1% (95% CI: 2.1-16.1%) after 23.1 years vs. 0% after 23.8 years; log-rank p = 0.0034). Patients operated with stems with a length equal to or longer than the calculated median length were also at a significantly higher risk of PPF during follow-up (10.2% (95% CI: 2.4-17.9%) after 23.8 years vs. 0% after 23.1 years; log-rank p = 0.0158). Diabetes at the time of index operation also significantly influenced the occurrence of a PPF during follow-up (n = 4 patients with PPF out of 107 without (4.0% (95% CI: 0.2-7.8%) after 23.8 years vs. n = 2 out of 14 with diabetes (15.4% (95% CI: 0-35.0%) after 21.1 years; log-rank p = 0.0368). The failure rate with implant removal as an endpoint due to aseptic loosening was 0%, and with infection it was 3.4% (95% CI: 0.1-6.7%), after 23.8 years. Conclusions: Although no removal of the implant due to a PPF was necessary, the cumulative risk for PPF after femoral revision with a tapered and fluted monobloc stem was higher in this long-term follow-up series compared to implant failure due to infection or aseptic loosening. Female gender and diabetes was associated with a significantly higher risk of PPF during follow-up. The use of longer stems than necessary is not preventive of PPF, and should be avoided.

Enhanced SIRT3 expression restores mitochondrial quality control mechanism to reverse osteogenic impairment in type 2 diabetes mellitus

Osteoporosis represents a prevalent and debilitating comorbidity in patients diagnosed with type 2 diabetes mellitus (T2DM), which is characterized by suppressed osteoblast function and disrupted bone microarchitecture. In this study, we utilized male C57BL/6 J mice to investigate the role of SIRT3 in T2DM. Decreased SIRT3 expression and impaired mitochondrial quality control mechanism are observed in both in vitro and in vivo models of T2DM. Mechanistically, SIRT3 suppression results in hyperacetylation of FOXO3, hindering the activation of the PINK1/PRKN mediated mitophagy pathway and resulting in accumulation of dysfunctional mitochondria. Genetical overexpression or pharmacological activation of SIRT3 restores deacetylation status of FOXO3, thus facilitating mitophagy and ameliorating osteogenic impairment in T2DM. Collectively, our findings highlight the fundamental regulatory function of SIRT3 in mitochondrial quality control, crucial for maintaining bone homeostasis in T2DM. These insights not only enhance our understanding of the molecular mechanisms underlying diabetic osteoporosis but also identify SIRT3 as a promising therapeutic target for diabetic osteoporosis.

Multi-scale inferomedial femoral neck bone quality in type 2 diabetes patients with fragility fracture

Both trabecular and cortical bone undergo changes at multiple scales. We previously demonstrated the multi-scale changes in trabecular bone quality that contribute to bone fragility in type 2 diabetes (T2D). The link between increased fragility in T2D and multi-scale changes in cortical bone and their interaction with glycation remains unclear. This study presents, first-ever, multi-scale cortical bone quality parameters in T2D patients after their first hip fracture. The study objective was to determine the association between cortical porosity (Ct.Po.), mechanical, material, and bone compositional properties in T2D. Inferomedial femoral neck (FN) bone tissue specimens were collected from patients (n = 10 with T2D, n = 25 age- and sex-matched non-diabetes controls) who underwent hip replacement surgery following the first hip fragility fracture. Bone mineral density at FN was found to be similar between groups. In T2D, Ct.Po was higher (p = 0.038), while ultimate stress (p = 0.021), ultimate strain (p = 0.040), post-yield strain (p = 0.011), toughness (p = 0.005), yield energy (p = 0.003), and post-yield energy (p = 0.004) were notably lower. Tissue compositional differences included lower gravimetric mineral/matrix (p = 0.017), higher non-enzymatic collagen cross-link ratio (NE-xLR) (p = 0.049) and higher sugar/matrix ratio (p = 0.042) in T2D. Fluorescent advanced glycation end-products (fAGEs) content was higher in T2D bone (p = 0.043). At the mesoscale, the fAGEs in the bone matrix are inversely related to the yield- and ultimate strain of T2D bone, and NE-xLR is negatively correlated with yield- and ultimate- stress in the T2D group. In conclusion, study findings demonstrate that elevated glycation weakens the mechanical integrity of cortical bone by reducing its ability to absorb energy and resist deformation, thereby contributing to bone fragility in T2D. The strong association of fAGEs with lower yield strain, along with the association of NE-xLR with lower yield- and ultimate stress, establishes a causal link between AGEs and the deterioration of cortical bone mechanical properties. These findings underscore the need for strategies targeting glycation and collagen quality to mitigate fracture risk in T2D patients.

Histochemical assessment of the femora of spontaneously diabetic torii-leprfa (SDT-fa/fa) rats that mimic type II diabetes

OBJECTIVE

To elucidate the mechanisms underlying diabetic osteoporosis, we conducted a comprehensive histological examination of the femora of Spontaneously Diabetic Torii-Leprfa (SDT-fa/fa) rats, an established model of obesity-related type 2 diabetes.

MATERIALS AND METHODS

Femora from 12 30-week-old male SDT-fa/fa rats and age-matched Sprague-Dawley (SD) rats (controls) were used for detailed histochemical analyses, including tartrate-resistant acid phosphatase (TRAP), cathepsin K, tissue nonspecific alkaline phosphatase (ALP), phosphoethanolamine/phosphocholine phosphatase 1 (PHOSPHO1), dentin matrix protein 1 (DMP-1), matrix extracellular phosphoglycoprotein (MEPE), sclerostin, osteocalcin staining, silver impregnation, von Kossa staining, and micro-computed tomography (CT).

RESULTS

Micro-CT and hematoxylin-eosin staining demonstrated significantly reduced trabecular bone volume in the femoral metaphyses of SDT-fa/fa rats. Although the number of TRAP-positive osteoclasts per bone surface remained comparable between both groups, SDT-fa/fa rats exhibited reduced areas of ALP-positive and PHOSPHO1-reactive mature osteoblasts/BS. Silver impregnation revealed a well-organized osteocytic lacunar-canalicular system in both groups. However, immunostaining identified aberrant DMP-1 and MEPE expression localized predominantly in the lacunae in SDT-fa/fa rats and in the lacunae and canaliculi of SD rats. Additionally, intense osteocalcin and sclerostin immunoreactivity was detected in osteocytes, along with a higher proportion of osteocalcin-positive osteocytes in SDT-fa/fa rats, distinguishing them from controls.

CONCLUSION

SDT-fa/fa rats displayed a significant decline in osteoblastic function and distinctive distribution patterns of osteocyte-derived peptides, suggesting that this diabetic model may manifest alterations in osteoblastic activity and the osteocytic lacunar-canalicular network.

The genetic basis of micro-structural fragility in murine dentin: Insights from type 2 diabetes mellitus

OBJECTIVES

Diabetes mellitus (DM) is a health issue affecting millions of people worldwide. Prolonged hyperglycemia increases the risk of pathological fractures; however, verifying this risk through bone analysis is challenging because of the heterogeneity of bone.

METHODS

The systemic effects of type 2 DM (T2DM) on calcified tissues were investigated by examining dentin in mice, focusing on the underlying cellular and molecular mechanisms. Mouse incisor dentin was selected because of its continuous growth, similar to the annual rings of wood, offering a unique opportunity to study the time-dependent deterioration of calcified tissue affected by T2DM. RNA sequencing of pulp-derived cells was used to identify transcriptomic alterations in a db/db mouse model (BKS.cg-Lepr[db]/Lepr[db]Jc). Structural and mechanical changes in dentin were evaluated using Raman spectroscopy and nanoindentation.

RESULTS

There was an increase in dentin volume in diabetic mice, accompanied by a deterioration in mechanical properties, particularly in primary dentin. This mechanical deterioration is likely to be associated with an inflammation-driven formation of abnormal dentin matrix caused by long-term hyperglycemia. No significant differences were observed in cross-linked collagen structures or advanced glycation end products.

CONCLUSIONS

The findings demonstrated that gene expression in T2DM affects dentin and bone, contributing to micro-structural fragility through protein production. The incisor model used in this study proved to be a versatile tool for assessing other diseases that affect the integrity of calcified tissues over time.

Risk factors for osteoporosis in elderly patients with type 2 diabetes: A protocol for systematic review and meta-analysis

BACKGROUND

Osteoporosis is a prevalent chronic result of diabetes. Osteoporosis susceptibility is raised by unstable blood glucose levels, oxidative stress, hormonal abnormalities, and other factors. Currently, there is no systematic review addressing the risk factors of osteoporosis in diabetes. This study intends to systematically assess the current risk factors related to diabetic osteoporosis (DOP) and provide suggestions for the improvement of therapy approaches.

METHODS AND ANALYSIS

We will search five English literature databases (PubMed, Embase, Web of Science, CINAHL, and Cochrane Library) and three Chinese databases (CNKI, WanFang, and SinoMed) from the starting point until December 31, 2024. We will perform a systematic examination and meta-analysis of cohort and case-control studies to identify all population-based risk factors for diabetic osteoporosis. Two researchers will independently assess the publication, extract data, and evaluate the quality and potential biases present in the study. We will utilize RevMan V.5.4 software and STATA 16.0 for data analysis. The included studies will be assessed using the Newcastle Ottawa Quality Assessment Instrument (NOS). If the heterogeneity of the included studies is higher than 50%, we will perform subgroup and sensitivity analysis to identify probable sources of heterogeneity. The assessment of publication bias will be conducted using funnel plot. Furthermore, we will employ the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the quality of evidence for each exposure and outcome.

DISCUSSION

This protocol aims to investigate the risk variables associated with DOP. We will summarize the current knowledge about factors influencing osteoporosis in diabetes. We strive to assist physicians with more extensive references for decision-making and facilitate the implementation of effective prevention strategies for DOP.

REGISTRATION

This study has been registered in the PROSPERO (CRD42024602637).

Fracture Risk Assessment in Metabolic Syndrome in Terms of Secondary Osteoporosis Potential. A Narrative Review

Osteoporosis is a major global public health problem with the associated bone fractures contributing significantly to both morbidity and mortality. In many countries, osteoporotic fractures will affect one in three women and one in five men over the age of 50. Similarly, diabetes, obesity, and metabolic syndrome (MetS) are among the leading public health problems due to their worldwide prevalence and burden on health budgets. Although seemingly disparate, metabolic disorders are known to affect bone health, and the interaction between fat and bone tissue is increasingly well understood. For example, it is now well established that diabetes mellitus (both type 1 and 2) is associated with fracture risk. In this narrative review, we focus on the potential link between MetS and bone health as expressed by bone mineral density and fracture risk. This narrative review demonstrates the association of MetS and its components with increased fracture risk, and also highlights the need for fracture risk assessment in patients with obesity and MetS.

Limb Osseointegration-How Important Is the Role of Nutrition in the Process?

BACKGROUND AND AIMS

Osseointegration (OI) surgery of the appendicular skeleton for repair in amputees is a treatment in which a metal implant is directly fixed to the residual bone and subsequently connected to a prosthetic limb via a transcutaneous connector through a small incision in the skin. Current treatment does not consider nutritional advice for patients undergoing the OI procedure. However, since the group of patients is very heterogeneous, the results may not be always satisfactory for patients and clinicians. Furthermore, in some individuals, incorrect nutrition and diet habits may lead to complications and rejection of the implant.

METHODS

We created an extensive narrative evaluation by conducting a methodical search. A comprehensive search was conducted across three major databases: PubMed, Embase, and Scopus. The search was carried out in October 2024 with no time limit specified. The approach involved using specific, pre-defined search terms, which were first applied in PubMed, followed by Embase and Scopus to ensure a broad and diverse range of articles was captured. The search process was refined by considering studies published in high-impact journals, as identified based on impact factors and subject relevance. To ensure consistency and rigor, the selection criteria were applied uniformly across all databases, and irrelevant or incomplete articles were excluded.

RESULTS

Based on the specific nature of the OI procedure, it is crucial to adapt patients' diets and nutrition after the process. To translate the findings from the reviewed literature into practical clinical guidance for osseointegration (OI) procedures, we developed dietary recommendations for both patients and clinicians, presented as proposed dietary plans and summarized in tables. These recommendations were informed by evidence from various studies, highlighting findings that were supported by randomized controlled trials (RCTs) as well as areas where the evidence remains inconclusive or unsupported by RCTs. Major vitamins and micro- and macroelements were distinguished and presented as guidelines for clinicians.

CONCLUSIONS

OI is currently the most promising therapeutic options for amputees. To promote efficient tissue healing and provide energy for rehabilitation, it is recommended to follow a healthy, well-balanced diet that contains all the essential micronutrients, macronutrients, vitamins, and minerals. We also provide suggestions for future studies.

Role of Anabolic Anti-Osteoporosis Therapy in Diabetes Subjects

Diabetes mellitus (DM) is a metabolic disorder that leads to the destruction of various tissues including bones. The pathogenesis of osteoporosis (OP) varies in DM due to many specific factors. DM increases the risk of fracture as well as post-fracture mortality. It is because of this fact that OP treatment should not be neglected in patients with DM. OP therapy comprises anabolic as well as anti-resorptive agents. Primary OP as observed in post-menopausal women is associated with high bone turnover, whereas OP in DM is a disease of low bone turnover. Therefore, anabolic agents seem to be quite promising in cases of OP in DM. Although the anti-fracture efficacy of these drugs is proven beyond any doubt in the general population without DM, evidence in persons with DM is limited. Among the anabolic agents, teriparatide has the most evidence in favor of its efficacy and safety in persons with DM. Studies evaluating other anabolic agents such as abaloparatide and romosozumab in diabetic osteopathy are scarce in the literature. Future studies specifically in both type 1 and type 2 DM populations are needed to evaluate the effects of osteoanabolic agents.

Association between diabetes mellitus and trochanteric bone mineral density in individuals with osteoporotic fractures: a retrospective study

Background

The relationship between diabetes mellitus (DM) and bone mineral density (BMD) in patients with osteoporotic fractures (OPFs) remains complex and heterogeneous, specifically between the genders. This study aimed to explore the association between diabetes status and trochanteric BMD in a cohort of patients with OPFs and elucidate the differences between male and female patients.

Methods

This retrospective analysis was performed on 710 admitted patients aged 50 years or older with OPFs. In this study, the exposure variable was diabetes status. Trochanteric BMD comprised the dependent variable. While controlling for covariance influences, generalized estimating equations (GEE) were applied to examine the independent link between diabetes status and trochanteric BMD in OPFs patients. Moreover, a subgroup analysis was also conducted to validate the result's stability.

Results

A substantial positive association was noted between diabetes status and trochanteric BMD in diabetic patients, as determined by the fully adjusted model (β = 0.017, 95% CI 0.001 to 0.033, p = 0.035). Furthermore, the sex-specific analysis showed a significant positive relationship between diabetes status and trochanteric BMD in male patients (β = 0.040, 95% CI 0.006 to 0.075, p = 0.022), whereas no significant relationship was observed in female patients (β = 0.010, 95% CI -0.008 to 0.028, p = 0.256).

Conclusion

This study highlighted the significant sex differences in the impact of diabetes on trochanteric BMD among patients with OPFs. The male diabetic patients had higher trochanteric BMD than their non-diabetic counterparts; however, this association was not evident in female patients. Further research is necessary to understand the underlying mechanisms that contribute to these sex-specific differences and to evaluate the clinical implications of managing fracture risk in diabetic patients.

Global and regional estimates of hip fracture burden associated with type 1 diabetes from 1990 to 2021

AIM

To assess the global and regional burden of hip fractures associated with type 1 diabetes (T1D) from 1990 to 2021.

MATERIALS AND METHODS

The population attributable fraction was calculated by combining the published risk ratio with T1D prevalence (age ≥ 20 years) from the Global Burden of Disease study to estimate the T1D-associated hip-fracture burden. Trends were assessed using the age-standardized incidence rate (ASIR) and estimated annual percentage change (EAPC).

RESULTS

The global incidence of T1D-related hip fractures was 290 180 in 2021 with an ASIR of 3.96 (95% confidence interval: 1.92-5.87) per 100 000 population and a male-to-female ratio of 0.54. At the super-regional level, the highest incidence (204 610) and ASIR (13.09 per 100 000 population; 6.40-25.53) were observed in high-income regions, in particular in Australasia and Western Europe. Notably, Australasia exhibited the highest EAPC, 2.90% in T1D-associated ASIR, followed by East Asia (2.73%). The incidence among those aged 45-64 years grew significantly in 14 regions over the past decade. Nationally, the ASIR increased in 166 countries from 1990 to 2021.

CONCLUSIONS

High-income regions experienced the greatest burden of T1D-associated hip fracture, while Australasia and East Asia witnessed the largest increase over the last 32 years. Prioritizing the promotion of T1D treatment and hip-fracture screening for middle-aged females living with T1D is crucial in these regions.

Does higher serum 25-hydroxyvitamin D levels will harm bone mineral density?: a cross-sectional study

OBJECTIVE

Vitamin D plays a critical role in the prevention and management of osteoporosis. However, there is an ongoing debate regarding the most effective vitamin D supplementation strategies for maintaining optimal bone mineral density (BMD) levels in adults. This study sought to establish the correlation between serum 25-hydroxyvitamin D [25(OH)D] levels and total BMD in a substantial population sample.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) for the 2011-2018 cycles, encompassing 11,375 adult participants, were analyzed. The primary variables of interest were serum 25(OH)D levels and BMD. A multivariable logistic regression model was utilized to account for relevant variables associated with these correlations.

RESULTS

A U-shaped relationship between serum 25(OH)D levels and BMD was observed. In males, a significant positive association was identified for 25(OH)D levels below 84.8 nmol/L (p < 0.0001), while levels above this threshold showed no significant correlation (p = 0.3377). In females, those with 25(OH)D levels below 31.4 nmol/L exhibited a significant positive association with BMD (p = 0.0010), but this association weakened and became marginally significant above this threshold (p = 0.0650).

CONCLUSIONS

For adult males, the optimal serum 25(OH)D level is 84.8 nmol/L, beyond which higher levels do not lead to increased BMD. A deficiency threshold for adult females should be above 31.4 nmol/L, as lower 25(OH)D levels are not conducive to BMD. These findings underscore the importance of maintaining appropriate vitamin D levels for bone health in both genders.

Predictive Factors for Cut-Out Risks of Unstable Trochanteric Fractures

Fractures of the trochanteric mass represent a significant proportion of hip fractures. These fractures often occur in the elderly due to compromised bone quality, leading to a high predisposition for instability at the fracture site. The study was conducted through a retrospective analysis of 1,259 hospitalizations in the Department of Orthopedics and Traumatology of the Bucharest University Emergency Hospital between 2022 and 2023, including patients with various types of trochanteric mass fractures: basicervical, per trochanteric, intertrochanteric, subtrochanteric, and trochanter-diaphyseal fractures. In the selection process, 59 patients who met the specific inclusion criteria for the study were chosen. The study population included 59 patients selected based on the afore-mentioned inclusion and exclusion criteria. For these patients, the demographic and clinical data revealed the following: the age of the patients varied between 26 and 91 years, with a mean of 74.69 years, a median of 80 years, and a standard deviation of 14.94 years. The first quartile was at 71 years, and the third quartile was at 84.5 years, resulting in an interquartile range of 13.5 years. The article aims to study prognostic factors for the risk of cut-out in the surgical treatment of unstable trochanteric fractures. A systematic evaluation of patient characteristics, fracture types, and surgical treatment options could establish the relevant factors in predicting the occurrence of cut-out. The results of this research have the potential to facilitate clinical decision-making, optimize treatment strategies, and improve outcomes for patients with unstable trochanteric fractures undergoing surgery.

Evaluating the relationship between glycemic control and bone fragility within the UK Biobank: observational and one-sample Mendelian randomization analyses

We aimed to: (1) examine the relationship between glycemic control, BMD estimated from heel ultrasound (eBMD) and fracture risk in individuals with type 1 (T1D) and type 2 diabetes (T2D) and (2) perform a one-sample Mendelian randomization (MR) study to explore potential causal associations between glycemic control, eBMD, and fractures. This study comprised 452 131 individuals from the UK Biobank with glycated hemoglobin A1C (HbA1c) and eBMD levels. At baseline, 4078 participants were diagnosed with T1D and 23 682 with T2D. HbA1c was used to classify patients into "adequately-" (ACD; n = 17 078; HbA1c < 7.0%/53 mmol/mol) and "inadequately-" (ICD; n = 10 682; HbA1c ≥ 7.0%/53 mmol/mol) controlled diabetes. In individuals with T1D, a 1% unit (11 mmol/mol) increase in HbA1c levels was associated with a 12% increase in fracture risk (HR: 1.12, 95% CI [1.05-1.19]). Fracture risk was highest in individuals with T1D and ICD (HR 2.84, 95%CI [2.53, 3.19]), followed by those with ACD (HR 2.26, 95%CI [1.91, 2.69]), as compared to subjects without diabetes. Evidence for a non-linear association between HbA1c and fracture risk was observed (F-test ANOVA p-value = 0.002) in individuals with T2D, with risk being increased at both low and high levels of HbA1c. Fracture risk between the T2D ACD and ICD groups was not significantly different (HR: 0.97, 95%CI [0.91-1.16]), despite increased BMD. In MR analyses genetically predicted higher HbA1c levels were not significantly associated with fracture risk (causal risk ratio: 1.04, 95%CI [0.95-1.14]). We did observe evidence of a non-linear causal association with eBMD (quadratic test p-value = 0.0002), indicating U-shaped relationship between HbA1c and eBMD. We obtained evidence that lower HbA1c levels will reduce fracture risk in patients with T1D. In individuals with T2D, lowering HbA1c levels can mitigate the risk of fractures up to a threshold, beyond which the risk may begin to rise again.

Metabolic reprogramming in skeletal cell differentiation

The human skeleton is a multifunctional organ made up of multiple cell types working in concert to maintain bone and mineral homeostasis and to perform critical mechanical and endocrine functions. From the beginning steps of chondrogenesis that prefigures most of the skeleton, to the rapid bone accrual during skeletal growth, followed by bone remodeling of the mature skeleton, cell differentiation is integral to skeletal health. While growth factors and nuclear proteins that influence skeletal cell differentiation have been extensively studied, the role of cellular metabolism is just beginning to be uncovered. Besides energy production, metabolic pathways have been shown to exert epigenetic regulation via key metabolites to influence cell fate in both cancerous and normal tissues. In this review, we will assess the role of growth factors and transcription factors in reprogramming cellular metabolism to meet the energetic and biosynthetic needs of chondrocytes, osteoblasts, or osteoclasts. We will also summarize the emerging evidence linking metabolic changes to epigenetic modifications during skeletal cell differentiation.

[Etiopathogenetic features of bone metabolism in patients with diabetes mellitus and Charcot foot]

Diabetic neuropathy is one of the most common diabetes mellitus complications associated with mediocalcinosis of the lower extremities, a significant decrease in feet bone mineral density, and a high incidence of cardiovascular disease. In most cases, calcium-phosphorus metabolism changes occur in patients with diabetic neuroarthropathy, or Charcot foot, when we can observe feet local osteoporosis, which in 90% of cases associated with a vessel's calcification of the lower extremities in the majority of diabetes population. A large number of studies presented literature have demonstrated that patients with Charcot foot can have accelerated bone metabolism and increased bone resorption. Patients with Charcot foot often have crucial abnormalities in the calcium-phosphorus parameters, bone metabolism, and levels of vitamin D and its metabolites. In addition, the duration of diabetes mellitus, the degree of its compensation widely affects the development of its micro- and macrovascular complications, which could also accelerate the development of mineral and bone disorders in these types of patients. Multifactorial pathogenesis of these disorders complicates the management of patients with a long and complicated course of diabetes mellitus. This review discusses the peculiarities of vitamin D metabolism, the importance of timely diagnosis in phosphorus-calcium disorders, and the specifics of therapy in these patients. Special attention is paid to the timely diagnosis of the Charcot's foots acute stage based on the bone marrow edema by MRI evaluation and the possibility of reducing the immobilization period.

Bone Fragility in Diabetes and its Management: A Narrative Review

Bone fragility is a serious yet under-recognised complication of diabetes mellitus (DM) that is associated with significant morbidity and mortality. Multiple complex pathophysiological mechanisms mediating bone fragility amongst DM patients have been proposed and identified. Fracture risk in both type 1 diabetes (T1D) and type 2 diabetes (T2D) continues to be understated and underestimated by conventional risk assessment tools, posing an additional challenge to the identification of at-risk patients who may benefit from earlier intervention or preventive strategies. Over the years, an increasing body of evidence has demonstrated the efficacy of osteo-pharmacological agents in managing skeletal fragility in DM. This review seeks to elaborate on the risk of bone fragility in DM, the underlying pathogenesis and skeletal alterations, the approach to fracture risk assessment in DM, management strategies and therapeutic options.

Research trends and hotspots on osteoporosis: a decade-long bibliometric and visualization analysis from 2014 to 2023

Background

Osteoporosis is characterized by diminished bone density and quality, compromised bone microstructure, and increased bone fragility, culminating in a heightened risk of fracture. Relatively few attempts have been made to survey the breadth of osteoporosis research using bibliometric approaches. This study aims to delineate the current landscape of osteoporosis research, offering clarity and visualization, while also identifying potential future directions for investigation.

Methods

We retrieved and filtered articles and reviews pertaining to osteoporosis from the Web of Science Core Collection database, specifically the Science Citation Index Expanded (SCI-E) edition, spanning the years 2014 to 2023. Informatics tools such as CiteSpace and VOSviewer were employed to dissect the intellectual framework, discern trends, and pinpoint focal points of interest within osteoporosis research.

Results

Our dataset comprised 33,928 osteoporosis-related publications, with a notable surge in annual publication numbers throughout the last decade. China and the United States lead in terms of research output. The University of California System contributed substantially to this body of work, with Amgen demonstrating the highest degree of centrality within the network. Cooper Cyrus emerged as a pivotal figure in the field. An analysis of highly-cited studies, co-citation networks, and keyword co-occurrence revealed that recent years have predominantly concentrated on elucidating mechanisms underlying osteoporosis, as well as its diagnosis, prevention, and treatment strategies. Burst detection analyses of citations and keywords highlighted osteoblasts, sarcopenia, gut microbiota, and denosumab as contemporary hotspots within osteoporosis research.

Conclusion

This bibliometric analysis has provided a visual representation of the fundamental knowledge structure, prevailing trends, and key focal areas within osteoporosis research. The identification of osteoblasts, sarcopenia, gut microbiota, and denosumab as current hotspots may guide future research endeavors. Continued efforts directed at understanding the mechanisms, fracture outcomes, diagnostics, and therapeutics related to osteoporosis are anticipated to deepen our comprehension of this complex disease.

Effect of abdominal tissue thickness on trabecular bone score and fracture risk in adults with diabetes: the Manitoba BMD registry

Individuals with type 2 diabetes have lower trabecular bone score (TBS) and increased fracture risk despite higher bone mineral density. However, measures of trabecular microarchitecture from high-resolution peripheral computed tomography are not lower in type 2 diabetes. We hypothesized that confounding effects of abdominal tissue thickness may explain this discrepancy, since central obesity is a risk factor for diabetes and also artifactually lowers TBS. This hypothesis was tested in individuals aged 40 years and older from a large DXA registry, stratified by sex and diabetes status. When DXA-measured abdominal tissue thickness was not included as a covariate, men without diabetes had lower TBS than women without diabetes (mean difference -0.074, P < .001). TBS was lower in women with versus without diabetes (mean difference -0.037, P < .001), and men with versus without diabetes (mean difference -0.007, P = .042). When adjusted for tissue thickness these findings reversed, TBS became greater in men versus women without diabetes (mean difference +0.053, P < .001), in women with versus without diabetes (mean difference +0.008, P < .001), and in men with versus without diabetes (mean difference +0.014, P < .001). During mean 8.7 years observation, incident major osteoporotic fractures were seen in 7048 (9.6%). Adjusted for multiple covariates except tissue thickness, TBS predicted fracture in all subgroups with no significant diabetes interaction. When further adjusted for tissue thickness, HR per SD lower TBS remained significant and even increased slightly. In conclusion, TBS predicts fractures independent of other clinical risk factors in both women and men, with and without diabetes. Excess abdominal tissue thickness in men and individuals with type 2 diabetes may artifactually lower TBS using the current algorithm, which reverses after accounting for tissue thickness. This supports ongoing efforts to update the TBS algorithm to directly account for the effects of abdominal tissue thickness for improved fracture risk prediction.

Bone Mineral Density, Osteoporosis Prevalence and Influential Factors in Osteogenesis in Patients with Beta Thalassemia Major: A Cross-Sectional Study

Background

Osteoporosis and osteopenia considered as severe problems in Beta thalassemia major (BTM) that can lead to bone fractures. We aimed to investigate bone mineral density status and the laboratory parameters related to bone metabolism in BTM patients and compare the statically differences between the mentioned parameters in the patients with or without bone fractures.

Methods

The results of laboratory parameters including; Hemoglobin (Hb), Calcium (Ca), Vitamin D (Vit D), Phosphorus (P), Magnesium (Mg), Alkaline Phosphatase (ALP), Ferritin (FER), Serum Iron (SFe), Thyroid Stimulating Hormone (TSH), T3, T4 and Parathyroid Hormone (PTH), and BMD (by using Dual-Energy X-ray Absorptiometry (DEXA) method) were investigated in 143 BTM patients from thalassemia center of Dezful University of Medical Sciences in 2023.

Results

Seventy-two women and 71 men with confirmed BTM diagnosis with age range (32.4 ± 9.7) were entered in the study. Laboratory parameters including TSH, T3, T4, ALP, FER 247) and SFe showed a significant difference between fracture and non-fracture groups respectively (P≤0.05). In this study, Z-Score between -1.1 and -2.4 was considered osteopenia, and below -2.5 was osteoporosis. Among the studied patients 36.6%, 39.1% and 24.2% had normal bone density, osteopenia and had osteoporosis respectively.

Conclusion

Osteopenia and osteoporosis had a high frequency among the studied patients that can prone them to bone fractures. Continuous examinations of laboratory tests, especially T3, T4, TSH, FER, SFE, can be helpful for faster diagnosis and therapeutic interventions to prevent the occurrence of osteopenia and pathological fractures.

Bone metabolism in diabetes: a clinician's guide to understanding the bone-glucose interplay

Skeletal fragility is an increasingly recognised, but poorly understood, complication of both type 1 and type 2 diabetes. Fracture risk varies according to skeletal site and diabetes-related characteristics. Post-fracture outcomes, including mortality risk, are worse in those with diabetes, placing these people at significant risk. Each fracture therefore represents a sentinel event that warrants targeted management. However, diabetes is a very heterogeneous condition with complex interactions between multiple co-existing, and highly correlated, factors that preclude a clear assessment of the independent clinical markers and pathophysiological drivers for diabetic osteopathy. Additionally, fracture risk calculators and routinely used clinical bone measurements generally underestimate fracture risk in people with diabetes. In the absence of dedicated prospective studies including detailed bone and metabolic characteristics, optimal management centres around selecting treatments that minimise skeletal and metabolic harm. This review summarises the clinical landscape of diabetic osteopathy and outlines the interplay between metabolic and skeletal health. The underlying pathophysiology of skeletal fragility in diabetes and a rationale for considering a diabetes-based paradigm in assessing and managing diabetic bone disease will be discussed.

Association between bone turnover markers, bone mineral density, and serum osteoglycine in middle-aged men with Type 2 Diabetes mellitus

BACKGROUND

Patients with Type 2 diabetes mellitus (T2DM) have decreased bone health. We aimed to investigate serum levels of bone turnover markers (BTMs) (markers of bone formation and bone resorption) and bone mineral density (BMD) at three sites (lumber, neck femur, and total femur) in middle-aged men with type 2 diabetes and to analyze the relationship between them. Also to evaluate serum osteoglycin as a novel marker and its relation to BTMs, BMD, and diabetic status.

METHODS

We recruited seventy-eight patients with T2DM and thirteen non-diabetic, male volunteers as a control group. BMD was measured using a DEXA scan. BTMs (carboxy-terminal crosslinking telopeptide of type 1 collagen [CTX] and procollagen type 1 N propeptide [P1NP]), osteoglycin, PTH, and vitamin D were estimated. Data was compared among subjects and statistical analysis was performed.

RESULTS

Most of the patients were having normal BMD with no significant difference between patients and the controls. BTMs and osteoglycin were significantly higher and vitamin D was significantly lower in the diabetic patients. Serum osteoglycin was positively correlated with DEXA Neck Femur (r = 0.233; p-value < 0.05).

CONCLUSION

Body mass index and Serum osteoglycin have a significant positive effect on BMD. Both markers of bone formation and bone resorption were increased indicating a state of increased bone turnover in T2DM.

Gut hormone analogues and skeletal health in diabetes and obesity: Evidence from preclinical models

Diabetes mellitus and obesity are rapidly growing worldwide. Aside from metabolic disturbances, these two disorders also affect bone with a higher prevalence of bone fractures. In the last decade, a growing body of evidence suggested that several gut hormones, including ghrelin, gastrin, glucose-dependent insulinotropic polypeptide (GIP), glucagon, and glucagon-like peptide-1 and 2 (GLP-1 and GLP-2, respectively) may affect bone physiology. Several gut hormone analogues have been developed for the treatment of type 2 diabetes and obesity, and could represent a new alternative in the therapeutic arsenal against bone fragility. In the present review, a summary of the physiological roles of these gut hormones and their analogues is presented at the cellular level but also in several preclinical models of bone fragility disorders including type 2 diabetes mellitus, especially on bone mineral density, microarchitecture and bone material properties. The present review also summarizes the impact of GLP-1 receptor agonists approved for the treatment of type 2 diabetes mellitus and the more recent dual or triple analogue on bone physiology and strength.

Effects of Exogenous GIP and GLP-2 on Bone Turnover in Individuals With Type 2 Diabetes

CONTEXT

Individuals with type 2 diabetes (T2D) have an increased risk of bone fractures despite normal or increased bone mineral density. The underlying causes are not well understood but may include disturbances in the gut-bone axis, in which both glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-2 (GLP-2) are regulators of bone turnover. Thus, in healthy fasting participants, both exogenous GIP and GLP-2 acutely reduce bone resorption.

OBJECTIVE

The objective of this study was to investigate the acute effects of subcutaneously administered GIP and GLP-2 on bone turnover in individuals with T2D.

METHODS

We included 10 men with T2D. Participants met fasting in the morning on 3 separate test days and were injected subcutaneously with GIP, GLP-2, or placebo in a randomized crossover design. Blood samples were drawn at baseline and regularly after injections. Bone turnover was estimated by circulating levels of collagen type 1 C-terminal telopeptide (CTX), procollagen type 1 N-terminal propeptide (P1NP), sclerostin, and PTH.

RESULTS

GIP and GLP-2 significantly reduced CTX to (mean ± SEM) 66 ± 7.8% and 74 ± 5.9% of baseline, respectively, compared with after placebo (P = .001). In addition, P1NP and sclerostin increased acutely after GIP whereas a decrease in P1NP was seen after GLP-2. PTH levels decreased to 67 ± 2.5% of baseline after GLP-2 and to only 86 ± 3.4% after GIP.

CONCLUSION

Subcutaneous GIP and GLP-2 affect CTX and P1NP in individuals with T2D to the same extent as previously demonstrated in healthy individuals.

Evaluating compliance with the care standard of proactively assessing bone health in patients with diabetes: a pilot audit of practice across Asia by the Asia Pacific Consortium on Osteoporosis (APCO)

This pilot audit explored how bone health is assessed patients with diabetes in diverse centres across Asia. Only 343 of 1092 (31%) audited patients had a bone health assessment, 27% of whom were diagnosed with osteoporosis. Quality improvement strategies are needed to address gaps in patient care in this area.

PURPOSE

The Asia Pacific Consortium on Osteoporosis (APCO) Framework outlines clinical standards for assessing and managing osteoporosis. A pilot audit evaluated adherence to clinical standard 4, which states that bone health should be assessed in patients with conditions associated with bone loss and/or increased fracture risk; this report summarises the audit findings in patients with diabetes. A secondary aim was to assess the practicality and real-world use of the APCO bone health audit tool kit.

METHODS

Eight centres across Asia participated in the pilot audit, selecting diabetes as the target group. Participants reviewed their practice records for at least 20 consecutively treated patients with the target condition. Questions covered routine investigations, bone health assessment, osteoporosis diagnosis, and patient referral pathways. Data were summarised descriptively.

RESULTS

The participants represented public hospitals, university medical centres, and private clinics from India, Malaysia, Pakistan, Singapore, Taiwan, and Vietnam that see an estimated total of 95,000 patients with diabetes per year. Overall, only 343 of 1092 audited patients (31%) had a bone health assessment. Osteoporosis was subsequently diagnosed in 92 of 343 (27%) patients.

CONCLUSION

Bone health was not assessed in most patients with diabetes. The results provide insight into current practices across diverse Asian centres and demonstrate the practical value of the audit tool kit. Participant feedback has been used to improve the tool kit. Results of this pilot audit are being used in the respective centres to inform quality improvement projects needed to overcome the gap in patient care.

Chronic pancreatitis-associated metabolic bone diseases: epidemiology, mechanisms, and clinical advances

Chronic pancreatitis (CP) is a progressive inflammatory disease with an increasing global prevalence. In recent years, a strong association between CP and metabolic bone diseases (MBDs), especially osteoporosis, has been identified, attracting significant attention in the research field. Epidemiological data suggest a rising trend in the incidence of MBDs among CP patients. Notably, recent studies have highlighted a profound interplay between CP and altered nutritional and immune profiles, offering insights into its linkage with MBDs. At the molecular level, CP introduces a series of biochemical disturbances that compromise bone homeostasis. One critical observation is the disrupted metabolism of vitamin D and vitamin K, both essential micronutrients for maintaining bone integrity, in CP patients. In this review, we provide physio-pathological perspectives on the development and mechanisms of CP-related MBDs. We also outline some of the latest therapeutic strategies for treating patients with CP-associated MBDs, including stem cell transplantation, monoclonal antibodies, and probiotic therapy. In summary, CP-associated MBDs represent a rising medical challenge, involving multiple tissues and organs, complex disease mechanisms, and diverse treatment approaches. More in-depth studies are required to understand the complex interplay between CP and MBDs to facilitate the development of more specific and effective therapeutic approaches.

Skeletal Fragility in Adult People Living With Type 1 Diabetes

Advances in the management of people with type 1 diabetes (T1D) led to longer life expectancy, but with it an aging population with age-associated conditions. While macrovascular and microvascular complications are widely recognized, bone fragility has received considerably less attention, although fractures lead to high morbidity and mortality. Hip fracture risk is up to sixfold higher in T1D than in nondiabetic controls and significantly higher than in type 2 diabetes. Hip fractures occur at a younger age, and the consequences are worse. The risk of nonvertebral fractures is also significantly increased. Altered bone quality is a major underlying mechanism. Areal BMD measured by DXA underestimates fracture risk. BMD testing is recommended in T1D patients with poor glycemic control and/or microvascular complications. Trabecular bone score is mildly reduced, and its ability to predict fractures in T1D is unknown. Bone turnover markers, particularly procollagen type 1 N-terminal propeptide, are suppressed and do not predict fracture risk in T1D. T1D-related risk factors for fractures include disease onset at age <20 years, longer disease duration, HbA1c ≥8%, hypoglycemic episodes and microvascular complications. Data regarding the efficacy of therapeutic interventions to prevent or treat skeletal fragility in T1D is scant. Adequate calcium and vitamin D intake and fall prevention are recommended. Antiosteoporosis therapies are recommended in T1D patients with previous hip or vertebral fragility fracture, more than 1 other fragility fracture, BMD T-score < -2.5 at the femoral neck or spine, and increased FRAX score. Fracture risk assessment needs to be part of the management of people with T1D.

Eight Weeks of Intermittent Exercise in Hypoxia, with or without a Low-Carbohydrate Diet, Improves Bone Mass and Functional and Physiological Capacity in Older Adults with Type 2 Diabetes

In an increasingly aging and overweight population, osteoporosis and type 2 diabetes (T2DM) are major public health concerns. T2DM patients experience prejudicial effects on their bone health, affecting their physical capacity. Exercise in hypoxia (EH) and a low-carbohydrate diet (LCD) have been suggested for therapeutic benefits in T2DM, improving bone mineral content (BMC) and glycemic control. This study investigated the effects of EH combined with an LCD on body composition and functional and physiologic capacity in T2DM patients. Older T2DM patients (n = 42) were randomly assigned to the following groups: (1) control group: control diet + exercise in normoxia; (2) EH group: control diet + EH; (3) intervention group: LCD + EH. Cardiopulmonary tests (BRUCE protocol), body composition (DEXA), and functional capacity (6MWT, handgrip strength) were evaluated. Body mass index (kg/m2) and body fat (%) decreased in all groups (p < 0.001). BMC (kg) increased in all groups (p < 0.001) and was significantly higher in the EH and EH + LCD groups (p < 0.001). VO2peak improved in all groups (p < 0.001), but more so in the hypoxia groups (p = 0.019). Functional capacity was increased in all groups (p < 0.001), but more so in the EH group in 6MWT (p = 0.030). EH with and without an LCD is a therapeutic strategy for improving bone mass in T2DM, which is associated with cardiorespiratory and functional improvements.

Bone Health in Patients With Type 2 Diabetes

The association between type 2 diabetes mellitus (T2DM) and skeletal fragility is complex, with effects on bone at the cellular, molecular, and biomechanical levels. As a result, people with T2DM, compared to those without, are at increased risk of fracture, despite often having preserved bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). Maladaptive skeletal loading and changes in bone architecture (particularly cortical porosity and low cortical volumes, the hallmark of diabetic osteopathy) are not apparent on routine DXA. Alternative imaging modalities, including quantitative computed tomography and trabecular bone score, allow for noninvasive visualization of cortical and trabecular compartments and may be useful in identifying those at risk for fractures. Current fracture risk calculators underestimate fracture risk in T2DM, partly due to their reliance on BMD. As a result, individuals with T2DM, who are at high risk of fracture, may be overlooked for commencement of osteoporosis therapy. Rather, management of skeletal health in T2DM should include consideration of treatment initiation at lower BMD thresholds, the use of adjusted fracture risk calculators, and consideration of metabolic and nonskeletal risk factors. Antidiabetic medications have differing effects on the skeleton and treatment choice should consider the bone impacts in those at risk for fracture. T2DM poses a unique challenge when it comes to assessing bone health and fracture risk. This article discusses the clinical burden and presentation of skeletal disease in T2DM. Two clinical cases are presented to illustrate a clinical approach in assessing and managing fracture risk in these patients.

Short- and long-term exposure to high glucose induces unique transcriptional changes in osteoblasts in vitro

Bone is increasingly recognized as a target for diabetic complications. In order to evaluate the direct effects of high glucose on bone, we investigated the global transcriptional changes induced by hyperglycemia in osteoblasts in vitro. Rat bone marrow-derived mesenchymal stromal cells were differentiated into osteoblasts for 10 days, and prior to analysis, they were exposed to hyperglycemia (25 mM) for the short-term (1 or 3 days) or long-term (10 days). Genes and pathways regulated by hyperglycemia were identified using mRNA sequencing and verified with qPCR. Genes upregulated by 1-day hyperglycemia were, for example, related to extracellular matrix organization, collagen synthesis and bone formation. This stimulatory effect was attenuated by 3 days. Long-term exposure impaired osteoblast viability, and downregulated, for example, extracellular matrix organization and lysosomal pathways, and increased intracellular oxidative stress. Interestingly, transcriptional changes by different exposure times were mostly unique and only 89 common genes responding to glucose were identified. In conclusion, short-term hyperglycemia had a stimulatory effect on osteoblasts and bone formation, whereas long-term hyperglycemia had a negative effect on intracellular redox balance, osteoblast viability and function.

ED-71 ameliorates bone regeneration in type 2 diabetes by reducing ferroptosis in osteoblasts via the HIF1α pathway

Eldecalcitol (ED-71), a novel active form of vitamin D, shows potential in treating osteoporosis. However, its underlying mechanisms of action remain to be determined. This study aimed to investigate the effect of ED-71 on bone regeneration and to illustrate its mode of action. The in-vitro model was developed using rat primary osteoblasts cultured under high-glucose conditions, and these cells were treated with ED-71. Additionally, an in vivo model of cranial bone defects was established in type 2 diabetic rats, and ED-71 was administered by gavage. The results demonstrated that ED-71 prevented osteoblast cell death, enhanced rat primary osteoblasts' osteogenic capacity, and attenuated the overexpression of hypoxia-inducible factor 1α (HIF1α) induced by high glucose levels. Furthermore, ED-71 increased glutathione peroxidase 4 (GPX4) levels and inhibited ferroptosis in response to hyperglycemic stimulation. Notably, interference with the HIF1α activator and ferroptosis activator Erastin significantly reduced the therapeutic effects of edetate osteolysis. These findings were further tested in vivo experiments. These results suggest that ED-71 activates the HIF1α pathway in vivo and in vitro, effectively relieving the ferroptosis induced by high glucose. Significantly, ED-71 may improve osteogenic disorders caused by diabetes.

Diagnosing Osteoporosis in Diabetes-A Systematic Review on BMD and Fractures

PURPOSE OF REVIEW

Recently, the American Diabetes Association updated the 2024 guidelines for Standards of Care in Diabetes and recommend that a T-score of - 2.0 in patients with diabetes should be interpreted as equivalent to - 2.5 in people without diabetes. We aimed to evaluate the most recent findings concerning the bone mineral density (BMD)-derived T-score and risk of fractures related to osteoporosis in subjects with diabetes.

RECENT FINDINGS

The dual-energy X-ray absorptiometry (DXA) scan is the golden standard for evaluating BMD. The BMD-derived T-score is central to fracture prediction and signifies both diagnosis and treatment for osteoporosis. However, the increased fracture risk in diabetes is not sufficiently explained by the T-score, complicating the identification and management of fracture risk in these patients. Recent findings agree that subjects with type 2 diabetes (T2D) have a higher T-score and higher fracture risk compared with subjects without diabetes. However, the actual number of studies evaluating the direct association of higher fracture risk at higher T-score levels is scant. Some studies support the adjustment based on the 0.5 BMD T-score difference between subjects with T2D and subjects without diabetes. However, further data from longitudinal studies is warranted to validate if the T-score treatment threshold necessitates modification to prevent fractures in subjects with diabetes.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Update on the utility of trabecular bone score (TBS) in clinical practice for the management of osteoporosis: a systematic review by the Egyptian Academy of Bone and Muscle Health

Trabecular bone score (TBS) is a grayscale textural assessment resulting from a computed evaluation of pixel gray-level variations in previously obtained lumbar spine DXA images. It is an index of bone microarchitecture correlated with parameters of bone strength. Higher values of TBS indicate a better microarchitecture, whereas lower values indicate a degraded microarchitecture. TBS can be used alongside Fracture Risk Assessment tool “FRAX” and bone mineral density (BMD) to enhance the assessment of fracture risk and to inform treatment initiation and monitoring. A systematic review was carried out aiming to update the evidence on the clinical use of the TBS in the management of both primary and secondary osteoporosis. Results revealed that in both primary and secondary osteoporosis, TBS enhances the prediction of fracture risk, and when adjust with BMD and clinical risk factors, it is able to inform the decision-making process regarding initiating osteoporosis therapy and the choice of anti-osteoporosis medication. Evidence also implies that TBS provides valuable adjunctive information in monitoring osteoporosis therapy. In conclusion, this work provides an up-to-date evidence-based review and recommendations which informs the utility of trabecular bone score in standard clinical practice.

Challenges of fracture risk assessment in Asian and Black women

OBJECTIVES

Bone mineral density (BMD) and fracture risk calculators (eg, the Fracture Risk Assessment Tool [FRAX]) guide primary prevention care in postmenopausal women. BMD scores use non-Hispanic White (NHW) reference data for T-score classification, whereas FRAX incorporates BMD, clinical risk factors, and population differences when calculating risk. This study compares findings among Asian, Black, and NHW women who underwent osteoporosis screening in a US health care system.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

Asian, Black, and NHW women aged 65 to 75 years who underwent BMD testing (with no recent fracture, osteoporosis therapy, metastatic cancer, multiple myeloma, metabolic bone disorders, or kidney replacement therapy) were compared across the following measures: femoral neck BMD (FN-BMD) T-score (normal ≥ -1, osteoporosis ≤ -2.5), high FRAX 10-year hip fracture risk (FRAX-Hip ≥ 3%), FRAX risk factors, and diabetes status.

RESULTS

Among 3640 Asian women, 23.8% had osteoporosis and 8.7% had FRAX-Hip scores of at least 3% (34.5% among those with osteoporosis). Among 11,711 NHW women, 12.3% had osteoporosis and 17.2% had FRAX-Hip scores of at least 3% (84.8% among those with osteoporosis). Among 1711 Black women, 68.1% had normal FN-BMD, 4.1% had BMD-defined osteoporosis, and 1.8% had FRAX-Hip scores of at least 3% (32.4% among those with osteoporosis). Fracture risk factors differed by group. Diabetes was 2-fold more prevalent in Black and Asian (35% and 36%, respectively) vs NHW (16%) women.

CONCLUSIONS

A large subset of Asian women have discordant BMD and FRAX scores, presenting challenges in osteoporosis management. Furthermore, FN-BMD and especially FRAX scores identified few Black women at high fracture risk warranting treatment. Studies should examine whether fracture risk assessment can be optimized in understudied racial minority populations, particularly when findings are discordant.

Design and clinical application of a risk prediction model for diabetic foot

OBJECTIVE

To construct and evaluate a nomogram prediction model for the risk of diabetic foot in patients with type 2 diabetes based on their clinical data, and to assist clinical healthcare professionals in identifying high-risk factors and developing targeted intervention measures.

METHODS

We retrospectively collected clinical data from 478 hospitalized patients with type 2 diabetes at the First Affiliated Hospital of Shantou University Medical College from January 2019 to December 2021. The patients were divided into a diabetic foot group (n=312) and a non-diabetic foot group (n=166) based on whether they had diabetic foot. The baseline data of both groups were collected. Univariate and multivariate analyses as well as logistic regression analysis were conducted to explore the risk factors for diabetic foot. A nomogram prediction model was established using the package "rms" version 4.3. The model was internally validated using the area under the receiver operating characteristic curve (AUC). Additionally, the decision curve analysis (DCA) was performed to evaluate the performance of the nomogram model.

RESULTS

The results from the logistic regression analysis revealed that being male, smoking, duration of diabetes, glycated hemoglobin, hyperlipidemia, and atherosclerosis were influencing factors for diabetic foot (all P<0.05). The AUC of the model in predicting diabetic foot was 0.804, with a sensitivity of 75.3% and specificity of 74.4%. Harrell's C-index of the nomogram prediction model for diabetic foot was 0.804 (95% CI: 0.762-0.844), with a threshold value of >0.675. The DCA findings demonstrated that the nomogram model provided a net clinical benefit.

CONCLUSION

The nomogram prediction model constructed in this study showed good predictive performance and can provide a basis for clinical workers to prevent and intervene in diabetic foot, thereby improving the overall diagnosis and treatment.

Efficacy of Osteoporosis Medications in Patients with Type 2 Diabetes

PURPOSE OF THE REVIEW

The purpose of the review is to summarise the current scientific evidence on the efficacy of osteoporosis medications in patients with type 2 diabetes.

RECENT FINDINGS

Type 2 diabetes (T2D) is a growing global epidemic. The highest prevalence is observed in the elderly, the same population affected by osteoporosis. Despite normal or even increased bone mineral density and low bone turnover, T2D is associated with an increased risk of fractures in most skeletal sites. These findings raised concerns over the efficacy of anti-osteoporosis drugs in this population. There is no randomised controlled trial designed specifically for people with T2D. However, observational studies and post-hoc analyses of randomised controlled trials have provided valuable insights into the effects of various anti-osteoporosis treatments in this population. Overall, most anti-osteoporosis drugs seem to have similar efficacy and safety profiles for people with and without type 2 diabetes. However, continued research and long-term safety data are needed to optimise treatment strategies and improve bone health outcomes in this population. The current evidence suggests that most anti-osteoporosis drugs exhibit comparable efficacy in people with and without T2D.

SiJunZi decoction ameliorates bone quality and redox homeostasis and regulates advanced glycation end products/receptor for advanced glycation end products and WNT/β-catenin signaling pathways in diabetic mice

ETHNOPHARMACOLOGICAL RELEVANCE

SiJunZi decoction (SJZD), one of the traditional Chinese medicine formulas, has been clinically and traditionally used to improve glucose and lipid metabolism and promote bone remodeling.

AIM OF THE STUDY

To study the actions and mechanisms of SJZD on bone remodeling in a type 2 diabetes mouse model.

MATERIALS AND METHODS

Diabetic mice generated with a high-fat diet (HFD) and streptozotocin (STZ) were subjected to SJZD treatment for 8 weeks. Blood glucose and lipid profile, redox status and bone metabolism were determined by ELISA or biochemical assays. Bone quality was evaluated by micro-CT, three-point bending assay and Fourier transform infrared spectrum (FTIR). Bone histomorphometry alterations were evaluated by Hematoxylin-Eosin (H&E), tartrate resistant acid phosphatase (TRAP) staining and Safranin O-fast green staining. The expressions of superoxide dismutase 1 (SOD1), advanced glycation end products (AGEs), receptor for advanced glycosylation end products (RAGE), phosphorylated nuclear factor kappa-B (p-NF-κB), NF-κB, cathepsin K, semaphorin 3A (Sema3A), insulin-like growth factor 1 (IGF1), p-GSK-3β, (p)-β-catenin, Runt-related transcription factor 2 (Runx2) and Cyclin D1 in the femurs and/or tibias were examined by Western blot or immunohistochemical staining. The main constituents in the SJZD aqueous extract were characterized by a HPLC/MS.

RESULTS

SJZD intervention improved glucose and lipid metabolism and preserved bone quality in the diabetic mice, in particular glucose tolerance, lipid profile, bone microarchitecture, strength and material composition. SJZD administration to diabetic mice preserved redox homeostasis in serum and bone marrow, and prevented an increase in AGEs, RAGE, p-NF-κB/NF-κB, cathepsin K, p-GSK-3β, p-β-catenin expressions and a decrease in Sema3A, IGF1, β-catenin, Runx2 and Cyclin D1 expressions in tibias and/or femurs. Thirteen compounds were identified in SJZD aqueous extract, including astilbin, liquiritin apioside, ononin, ginsenoside Re, Rg1, Rb1, Rb2, Ro, Rb3, Rd, notoginsenoside R2, glycyrrhizic acid, and licoricesaponin B2.

CONCLUSIONS

SJZD ameliorates bone quality in diabetic mice possibly via maintaining redox homeostasis. The mechanism governing these alterations are possibly related to effects on the AGEs/RAGE and Wnt/β-catenin signaling pathways. SJZD may offer a novel source of drug candidates for the prevention and treatment of type 2 diabetes and osteoporosis.

Obesity and Skeletal Fragility

Skeletal fracture has recently emerged as a complication of obesity. Given the normal or better than normal bone mineral density (BMD), the skeletal fragility of these patients appears to be a problem of bone quality rather than quantity. Type 2 diabetes mellitus (T2DM), the incidence of which increases with increasing body mass index, is also associated with an increased risk for fractures despite a normal or high BMD. With the additional bone pathology from diabetes itself, patients with both obesity and T2DM could have a worse skeletal profile. Clinically, however, there are no available methods for identifying those who are at higher risk for fractures or preventing fractures in this subgroup of patients. Weight loss, which is the cornerstone in the management of obesity (with or without T2DM), is also associated with an increased risk of bone loss. This review of the literature will focus on the skeletal manifestations associated with obesity, its interrelationship with the bone defects associated with T2DM, and the available approach to the bone health of patients suffering from obesity.

Femoral bone mineral density at the time of hip fracture is higher in women with versus without type 2 diabetes mellitus: a cross-sectional study

PURPOSE

To compare femoral bone mineral density (BMD) levels in hip-fracture women with versus without type 2 diabetes mellitus (T2DM). We hypothesized that BMD levels could be higher in the women with T2DM than in controls and we aimed to quantify the BMD discrepancy associated with the presence of T2DM.

METHODS

At a median of 20 days after the occurrence of an original hip fracture due to fragility we measured BMD by dual-energy x-ray absorptiometry at the non-fractured femur.

RESULTS

We studied 751 women with subacute hip fracture. Femoral BMD was significantly higher in the 111 women with T2DM than in the 640 without diabetes: mean T-score between-group difference was 0.50, (95% CI from 0.30 to 0.69, P < 0.001). The association between the presence of T2DM and femoral BMD persisted after adjustment for age, body mass index, hip-fracture type, neurologic diseases, parathyroid hormone, 25-hydroxyvitamin D and estimated glomerular filtration rate (P < 0.001). For a woman without versus with T2DM, the adjusted odds ratio to have a femoral BMD T-score below the threshold of - 2.5 was 2.13 (95% CI from 1.33 to 3.42, P = 0.002).

CONCLUSIONS

Fragility fractures of the hip occurred in women with T2DM at a femoral BMD level higher than in control women. In the clinical assessment of fracture risk, we support the adjustment based on the 0.5 BMD T-score difference between women with and without T2DM, although further data from robust longitudinal studies is needed to validate the BMD-based adjustment of fracture risk estimation.

American Diabetes Association Professional Practice Committee, ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Cusi K, Ekhlaspour L, Fleming TK, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Napoli N, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Verduzco-Gutierrez M, Younossi ZM, Gabbay RA. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Use of Fracture Risk Assessment Tool in clinical practice and Fracture Risk Assessment Tool future directions

Fracture Risk Assessment Tool is a free, online fracture risk calculator which can be used to predict 10-year fracture risk for women and men over age 50 years. It incorporates seven clinical risk factors and bone density to give a 10-year risk of major osteoporotic fracture and hip fracture. This dynamic tool can be used with patients at the bedside to help guide treatment decisions. There are some limitations to Fracture Risk Assessment Tool, with the most central limitation being the fact that inputs are binary. Much research has been done to try to refine Fracture Risk Assessment Tool to allow for more accurate risk prediction, and this article describes the data for adjusting Fracture Risk Assessment Tool depending on the clinical scenario such as the dose of glucocorticoid use, presence of diabetes and others. Recently, the new FRAXplus tool has been developed to address many of these concerns and will likely replace the old Fracture Risk Assessment Tool in the future. At the current time, it is available in beta form.