La paradoja diabética: densidad mineral ósea y fractura en la diabetes tipo 2

Ethnic Variations in the Levels of Bone Biomarkers (Osteoprostegerin, Receptor Activator of Nuclear Factor Kappa-Β Ligand and Glycoprotein Non-Metastatic Melanoma Protein B) in People with Type 2 Diabetes

The global incidence of Type 2 diabetes (T2D) is on the rise, fueled by factors such as obesity, sedentary lifestyles, socio-economic factors, and ethnic backgrounds. T2D is a multifaceted condition often associated with various health complications, including adverse effects on bone health. This study aims to assess key biomarkers linked to bone health and remodeling-Osteoprotegerin (OPG), Receptor Activator of Nuclear Factor Kappa-Β Ligand (RANKL), and Glycoprotein Non-Metastatic Melanoma Protein B (GPNMB)-among individuals with diabetes while exploring the impact of ethnicity on these biomarkers. A cross-sectional analysis was conducted on a cohort of 2083 individuals from diverse ethnic backgrounds residing in Kuwait. The results indicate significantly elevated levels of these markers in individuals with T2D compared to non-diabetic counterparts, with OPG at 826.47 (405.8) pg/mL, RANKL at 9.25 (17.3) pg/mL, and GPNMB at 21.44 (7) ng/mL versus 653.75 (231.7) pg/mL, 0.21 (9.94) pg/mL, and 18.65 (5) ng/mL in non-diabetic individuals, respectively. Notably, this elevation was consistent across Arab and Asian populations, except for lower levels of RANKL observed in Arabs with T2D. Furthermore, a positive and significant correlation between OPG and GPNMB was observed regardless of ethnicity or diabetes status, with the strongest correlation (r = 0.473, p < 0.001) found among Arab individuals with T2D. Similarly, a positive and significant correlation between GPNMB and RANKL was noted among Asian individuals with T2D (r = 0.401, p = 0.001). Interestingly, a significant inverse correlation was detected between OPG and RANKL in non-diabetic Arab individuals. These findings highlight dysregulation in bone remodeling markers among individuals with T2D and emphasize the importance of considering ethnic variations in T2D-related complications. The performance of further studies is warranted to understand the underlying mechanisms and develop interventions based on ethnicity for personalized treatment approaches.

Diabetes and osteoporosis: a two-sample mendelian randomization study

BACKGROUND

The effects on bone mineral density (BMD)/fracture between type 1 (T1D) and type 2 (T2D) diabetes are unknown. Therefore, we aimed to investigate the causal relationship between the two types of diabetes and BMD/fracture using a Mendelian randomization (MR) design.

METHODS

A two-sample MR study was conducted to examine the causal relationship between diabetes and BMD/fracture, with three phenotypes (T1D, T2D, and glycosylated hemoglobin [HbA1c]) of diabetes as exposures and five phenotypes (femoral neck BMD [FN-BMD], lumbar spine BMD [LS-BMD], heel-BMD, total body BMD [TB-BMD], and fracture) as outcomes, combining MR-Egger, weighted median, simple mode, and inverse variance weighted (IVW) sensitivity assessments. Additionally, horizontal pleiotropy was evaluated and corrected using the residual sum and outlier approaches.

RESULTS

The IVW method showed that genetically predicted T1D was negatively associated with TB-BMD (β = -0.018, 95% CI: -0.030, -0.006), while T2D was positively associated with FN-BMD (β = 0.033, 95% CI: 0.003, 0.062), heel-BMD (β = 0.018, 95% CI: 0.006, 0.031), and TB-BMD (β = 0.050, 95% CI: 0.022, 0.079). Further, HbA1c was not associated with the five outcomes (β ranged from - 0.012 to 0.075).

CONCLUSIONS

Our results showed that T1D and T2D have different effects on BMD at the genetic level. BMD decreased in patients with T1D and increased in those with T2D. These findings highlight the complex interplay between diabetes and bone health, suggesting potential age-specific effects and genetic influences. To better understand the mechanisms of bone metabolism in patients with diabetes, further longitudinal studies are required to explain BMD changes in different types of diabetes.

Deciphering the complex relationship between type 2 diabetes and fracture risk with both genetic and observational evidence

The 'diabetic bone paradox' suggested that type 2 diabetes (T2D) patients would have higher areal bone mineral density (BMD) but higher fracture risk than individuals without T2D. In this study, we found that the genetically predicted T2D was associated with higher BMD and lower risk of fracture in both weighted genetic risk score (wGRS) and two-sample Mendelian randomization (MR) analyses. We also identified ten genomic loci shared between T2D and fracture, with the top signal at SNP rs4580892 in the intron of gene RSPO3. And the higher expression in adipose subcutaneous and higher protein level in plasma of RSPO3 were associated with increased risk of T2D, but decreased risk of fracture. In the prospective study, T2D was observed to be associated with higher risk of fracture, but BMI mediated 30.2% of the protective effect. However, when stratified by the T2D-related risk factors for fracture, we observed that the effect of T2D on the risk of fracture decreased when the number of T2D-related risk factors decreased, and the association became non-significant if the T2D patients carried none of the risk factors. In conclusion, the genetically determined T2D might not be associated with higher risk of fracture. And the shared genetic architecture between T2D and fracture suggested a top signal around RSPO3 gene. The observed effect size of T2D on fracture risk decreased if the T2D-related risk factors could be eliminated. Therefore, it is important to manage the complications of T2D to prevent the risk of fracture.

La osteocalcina se asocia con la densidad mineral ósea y los polimorfismos del gen VDR en la diabetes tipo 1 y 2

Objetivos

El metabolismo óseo se encuentra alterado en la diabetes mellitus (DM). El objetivo de este estudio es evaluar la relación entre los marcadores de remodelado óseo (MRO), los polimorfismos en el gen receptor de la vitamina D (VDR) y la densidad mineral ósea (DMO) en la DM tipo 1 (T1D) y tipo 2 (T2D).

Métodos

Se incluyó a 165 pacientes (53 T1D y 112 T2D). La DMO se midió mediante absorciometría de rayos X de energía dual (DEXA). Se realizó un análisis de la osteocalcina (OC) en plasma, beta-CrossLaps (β-CTX), propéptido aminoterminal del procolágeno tipo 1 (P1NP) y los polimorfismos en el gen VDR.

Resultados

Se incluyó a 53 pacientes con T1D (41 años (31–48)) y 112 con T2D (60 años [51–66]). No se observaron diferencias estadísticamente significativas en relación a la DMO. Los pacientes con T1D presentaron niveles superiores de OC (p<0,001) y P1NP (p<0,001). Las áreas bajo la curva para la predicción de patología ósea para la OC fueron 0,732 (p=0,038) en T1D y 0,697 (p=0,007) en T2D. Se observó una relación estadísticamente significativa entre el alelo A de BsmI (p=0,03), el alelo A de ApaI (p=0,04) y el alelo C de Taql (p=0,046) y una menor DMO. Así mismo, se encontró una correlación significativa entre los niveles elevados de OC y el alelo G de BsmI (p=0,044), el alelo C de ApaI (p=0,011), el alelo T de Taql (p=0,006) y el alelo C de FokI (p=0,004).

Conclusiones

El elevado valor predictivo negativo del punto de corte de la OC indica que la OC podría ser útil a la hora de descartar el riesgo de pérdida ósea, lo que permitiría diseñar un tratamiento personalizado para prevenir dicha patología.

Osteocalcin associates with bone mineral density and VDR gene polymorphisms in type 1 and type 2 diabetes

Objectives

Bone metabolism is impaired in diabetes mellitus (DM). Our objective is to evaluate the association of bone turnover markers (BTM) and vitamin D receptor (VDR) gene polymorphisms with bone mineral density (BMD) in DM type 1 (T1D) and DM type 2 (T2D).

Methods

A total of 165 patients (53 T1D and 112 T2D) were enrolled. BMD was measured by dual-energy X-ray absorptiometry (DEXA). Plasma osteocalcin (OC), beta-CrossLaps (β-CTX) and N-amino terminal propeptide of type I collagen (P1NP) and VDR gene polymorphisms were evaluated.

Results

Participants were 53 T1D (41 years [31-48]) and 112 T2D (60 years [51-66]). BMD were not statistically different between the groups. OC (p<0.001) and P1NP levels (p<0.001) were higher in patients with T1D. The areas under the curve for the prediction of bone pathology were 0.732 (p=0.038) for OC in T1D and 0.697 (p=0.007) in T2D. A significant association was found between lower lumbar BMD and the A allele of BsmI (p=0.03), the A allele of ApaI (p=0.04) and the allele C of the Taql (p=0.046). Also, a significant correlation was found with higher OC levels and the G allele of BsmI (p=0.044), C allele of ApaI (p=0.011), T allele of Taql (p=0.006) and with C allele of FokI (p=0.004).

Conclusions

The high negative predictive value of the cut-off point for OC suggests that could be useful in excluding the risk suffering bone loss, allowing offering a personalized clinical approach to prevent this pathology.

The association between type 2 diabetes mellitus/prediabetes status and femoral neck bone mineral density in old adults

BACKGROUND

The prevalence of both type 2 diabetes mellitus (T2DM) and osteoporosis has been increasing among older individuals, with these two health conditions often coexisting. Our aim in this study was to evaluate the association between T2DM status and bone mineral density (BMD) of the femoral neck among older adults in the United States.

METHODS

This was a retrospective analysis of the data from 5695 adults, 60-80 years of age. The data were obtained from the National Health and Nutrition Examination Survey, for the following years: 2005-2006, 2007-2008, 2009-2010, 2013-2014, and 2017-2018. Weighted multivariable regression analyses, with subgroup analyses as appropriate, were performed to identify an association between T2DM/prediabetes status and femoral BMD and mediating factors.

RESULTS

There was a significant positive association between T2DM/prediabetes status and femoral neck BMD among older women, but not men, after adjusting for body mass index (BMI). On subgroup analysis, stratified by BMI, the significant positive association was retained for T2DM women with a BMI of 25-29.9 kg/m2 (β, 0.030; 95% CI, 0.007-0.052) or ≥30 kg/m2 (β, 0.029; 95% CI, 0.007-0.05), and for prediabetes women with a BMI of 25-29.9 kg/m2 (β, 0.016; 95% CI, 0.001-0.030).

CONCLUSIONS

The association between a positive T2DM/prediabetes status and femoral neck BMD differed by sex among older individuals, with the association being further modulated by BMI. For women with a BMI of 25-29.9 kg/m2 or ≥30 kg/m2, T2DM was associated with a significantly higher femoral neck BMD, compared to the non-diabetes group.

The relationship between adipokine levels and bone mass-A systematic review

INTRODUCTION

Adipose tissue is the source of a broad array of signalling molecules (adipokines), which mediate interorgan communication and regulate metabolic homeostasis. Alterations in adipokine levels have been causally implicated in various metabolic disorders, including changes in bone mass. Osteoporosis is the commonest progressive metabolic bone disease, characterized by elevated risk of fragility fractures as a result of a reduced bone mass and microarchitectural deterioration. The effects of different adipokines on bone mass have been studied in an attempt to identify novel modulators of bone mass or diagnostic biomarkers of osteoporosis.

METHODS

In this review, we sought to aggregate and assess evidence from independent studies that quantify specific adipokines and their effect on bone mineral density (BMD).

RESULTS

A literature search identified 57 articles that explored associations between different adipokines and BMD. Adiponectin and leptin were the most frequently studied adipokines, with most studies demonstrating that adiponectin levels are associated with decreased BMD at the lumbar spine and femoral neck. Conversely, leptin levels are associated with increased BMD at these sites. However, extensive heterogeneity with regards to sample size, characteristics of study subjects, ethnicity, as well as direction and magnitude of effect at specific skeletal anatomical sites was identified. The broad degree of conflicting findings reported in this study can be attributed several factors. These include differences in study design and ascertainment criteria, the analytic challenges of quantifying specific adipokines and their isoforms, pre-analytical variables (in particular patient preparation) and confounding effects of co-existing disease.

CONCLUSIONS

This review highlights the biological relevance of adipokines in bone metabolism and reinforces the need for longitudinal research to elucidate the causal relationship of adipokines on bone mass.

Peripheral quantitative computed tomography-derived bone parameters in men with impaired fasting glucose and diabetes

INTRODUCTION

Individuals with type 2 diabetes mellitus (T2DM) are at higher risk of fracture, but paradoxically do not have reduced bone mineral density. We investigated associations between peripheral quantitative computed tomography (pQCT) and glycaemia status.

MATERIALS AND METHODS

Participants were men (n = 354, age 33-92 year) from the Geelong Osteoporosis Study. Diabetes was defined by fasting plasma glucose (FPG) ≥ 7.0 mmol/L, self-report of diabetes and/or antihyperglycaemic medication use and impaired fasting glucose (IFG) as FPG 5.6-6.9 mmol/L. Bone measures were derived using pQCT (XCT2000) at 4% and 66% radial and tibial sites. Linear regression was used, adjusting for age, body mass index and socio-economic status.

RESULTS

At the 4% site, men with T2DM had lower adjusted bone total area, trabecular area and cortical area at the radius (all - 6.2%) and tibia (all - 6.4%) compared to normoglycaemia. Cortical density was higher for T2DM at the radius (+ 5.8%) and tibia (+ 8.0%), as well as adjusted total bone density at the tibial site (+ 6.1%). At the 66% site, adjusted total bone area and polar stress strain index were lower for T2DM at the radius (- 4.3% and - 8.0%). Total density was also higher for T2DM (+ 1.2%). Only cortical density at the 4% tibial site was different between IFG and normoglycaemia in adjusted analyses (+ 4.5%).

CONCLUSION

Men with T2DM had lower total bone area, trabecular area, cortical area and polar stress strain index than the other two groups; however, total density and cortical density were higher. Only one difference was observed between IFG and normoglycaemia; increased tibial cortical density.

Weight change and the risk of hip fractures in patients with type 2 diabetes: a nationwide cohort study

Both weight gain and weight loss in type 2 diabetic population were associated with increased risk of hip fracture, while maintaining weight lowered the risk of hip fracture. Regarding the risk of hip fracture, we can propose active monitoring to maintain the weight of type 2 diabetes patients.

INTRODUCTION

In type 2 diabetes, patients are often asked to control their weight in order to reduce their diabetic morbidity. The American Diabetes Association recommends that diabetic patients conduct high-intensity interventions for regulating diet, physical activity, and behavior to reduce weight, followed by long-term comprehensive weight maintenance programs. Although such weight control attempts are required in diabetic patients, there are few studies on the effect of weight change on hip fracture in this population. We aim to investigate the association between body weight change and the incidence of hip fracture in subjects with type 2 diabetes using large-scale, nationwide cohort data on the Korean population.

MATERIALS AND METHODS

A total of 1,447,579 subjects (894,204 men and 553,375 women) > 40 years of age, who were diagnosed with type 2 diabetes, were enrolled in this study. Weight change within 2 years was divided into five categories: from weight loss ≥ 10% to weight gain ≥ 10%. The hazard ratios (HRs) and 95% confidence intervals for the incidence of hip fracture were analyzed, compared with the reference of the stable weight group (weight change < 5%).

RESULTS

Among 5 weight change groups, more than 10% weight loss showed the highest HR (HR, 1.605; 95% CI, 1.493 to 1.725), followed by more than 10% weight gain (HR, 1.457; 95% CI, 1.318 to 1.612). The effect of weight change on hip fracture risk was greater in males than in females, and those under 65 years of age were greater than those over 65 years of age. Baseline BMI did not play a role of weight change affecting the risk of hip fracture. The HR for hip fracture of subjects with regular exercise was lower than those without regular exercise.

CONCLUSIONS

In the type 2 diabetes population, both weight gain and weight loss were significantly associated with a higher risk of hip fracture, whereas maintaining body weight reduced the risk of hip fracture the most.

Factors associated with trabecular bone score in postmenopausal women with type 2 diabetes and normal bone mineral density

BACKGROUND

Osteoporosis and type 2 diabetes (T2D) have been recognized as a widespread comorbidity leading to excess mortality and an enormous healthcare burden. In T2D, bone mineral density (BMD) may underestimate the risk of low-energy fractures as bone quality is reduced. It was hypothesized that a decrease in the trabecular bone score (TBS), a parameter assessing bone microarchitecture, may be an early marker of impaired bone health in women with T2D.

AIM

To identify clinical and body composition parameters that affect TBS in postmenopausal women with T2D and normal BMD.

METHODS

A non-interventional cross-sectional comparative study was conducted. Potentially eligible subjects were screened at tertiary referral center. Postmenopausal women with T2D, aged 50-75 years, with no established risk factors for secondary osteoporosis, were included. BMD, TBS and body composition parameters were assessed by dual-energy X-ray absorptiometry. In women with normal BMD, a wide range of anthropometric, general and diabetes-related clinical and laboratory parameters were evaluated as risk factors for TBS decrease using univariate and multivariate regression analysis and analysis of receiver operating characteristic (ROC) curves.

RESULTS

Three hundred twelve women were initially screened, 176 of them met the inclusion criteria and underwent dual X-ray absorptiometry. Those with reduced BMD were subsequently excluded; 96 women with normal BMD were included in final analysis. Among them, 43 women (44.8%) showed decreased TBS values (≤ 1.31). Women with TBS ≤ 1.31 were taller and had a lower body mass index (BMI) when compared to those with normal TBS (Р = 0.008 and P = 0.007 respectively). No significant differences in HbA1c, renal function, calcium, phosphorus, alkaline phosphatase, PTH and 25(ОН)D levels were found. In a model of multivariate linear regression analysis, TBS was positively associated with gynoid fat mass, whereas the height and androgen fat mass were associated negatively (all P < 0.001). In a multiple logistic regression, TBS ≤ 1.31 was associated with lower gynoid fat mass (adjusted odd ratio [OR], 0.9, 95% confidence interval [CI], 0.85-0.94, P < 0.001), higher android fat mass (adjusted OR, 1.13, 95%CI, 1.03-1.24, P = 0.008) and height (adjusted OR, 1.13, 95%CI, 1.05-1.20, P < 0.001). In ROC-curve analysis, height ≥ 162.5 cm (P = 0.04), body mass index ≤ 33.85 kg/m² (P = 0.002), gynoid fat mass ≤ 5.41 kg (P = 0.03) and android/gynoid fat mass ratio ≥ 1.145 (P < 0.001) were identified as the risk factors for TBS reduction.

CONCLUSION

In postmenopausal women with T2D and normal BMD, greater height and central adiposity are associated with impaired bone microarchitecture.

Analysis of high-intensity interval training on bone mineral density in an experimental model of type 2 diabetes

PURPOSE

To analyze the effect of high-intensity interval training (HIIT) on bone mineral density (BMD) in a model of type 2 diabetes mellitus.

METHODS

Thirty-two male, adult, 12-week-old rats (Rattus norvegicus), of the Wistar lineage, were used. The animals induced to the experimental model received a high fat diet for 10 days and, after that period, intraperitoneal injection of streptozotocin (40 mg·kg-1), dissolved in 20 mmol·L-1 sodium citrate solution (pH = 4.5). The experimental group of diabetes was formed by the animals that, 48 h after the injection of streptozotocin, had fasting blood glucose > 250 mg·dL-1). The animals were randomly divided into four groups with eight animals each: HIIT experimental diabetes; HIIT control; sedentary experimental diabetes and sedentary control. The animals in the HIIT group performed an aerobic exercise protocol on a treadmill inclined at an angle of 15° to the horizontal, with interspersed intensity. Five weekly sessions, lasting 49 min each, were held for 6 weeks. The analysis of cortical bone density (CBD) and BMD were performed by X-ray images using the In-Vivo Xtreme II/Bruker system.

RESULTS

For CBD and BMD, when comparing diabetes and control groups, a significant difference was seen between groups in relation to HIIT (p = 0.007). Animals submitted and not submitted to HIIT in the same group showed a significant difference between groups in relation to diabetes (p < 0.001).

CONCLUSIONS

The HIIT experimental diabetes group had increased CBD and BMD in comparison with the sedentary experimental diabetes group.

Evaluation of Quality and Bone Microstructure Alterations in Patients with Type 2 Diabetes: A Narrative Review

Bone fragility is a common complication in subjects with type 2 diabetes mellitus (T2DM). However, traditional techniques for the evaluation of bone fragility, such as dual-energy X-ray absorptiometry (DXA), do not perform well in this population. Moreover, the Fracture Risk Assessment Tool (FRAX) usually underestimates fracture risk in T2DM. Importantly, novel technologies for the assessment of one microarchitecture in patients with T2DM, such as the trabecular bone score (TBS), high-resolution peripheral quantitative computed tomography (HR-pQCT), and microindentation, are emerging. Furthermore, different serum and urine bone biomarkers may also be useful for the evaluation of bone quality in T2DM. Hence, in this article, we summarize the limitations of conventional tools for the evaluation of bone fragility and review the current evidence on novel approaches for the assessment of quality and bone microstructure alterations in patients with T2DM.

Do patients with type 2 diabetes have impaired hip bone microstructure? A study using 3D modeling of hip dual-energy X-ray absorptiometry

AIM

Patients with type 2 diabetes (T2DM) have more risk of bone fractures. However, areal bone mineral density (aBMD) by conventional dual-energy x-ray absorptiometry (DXA) is not useful for identifying this risk. This study aims to evaluate 3D-DXA parameters determining the cortical and trabecular compartments in patients with T2DM compared to non-diabetic subjects and to identify their determinants.

MATERIALS AND METHODS

Case-control study in 111 T2DM patients (65.4 ± 7.6 years old) and 134 non-diabetic controls (64.7 ± 8.6-year-old). DXA, 3D-DXA modelling via 3D-Shaper software and trabecular bone score (TBS) were used to obtain aBMD, cortical and trabecular parameters, and lumbar spine microarchitecture, respectively. In addition, biochemical markers as 25-hydroxyvitamin d, type I procollagen N-terminal propeptide (P1NP), C-terminal telopeptide of type I collagen (CTX), and glycated haemoglobin (HbA1c) were analysed.

RESULTS

Mean-adjusted values showed higher aBMD (5.4%-7.7%, ES: 0.33-0.53) and 3D-DXA parameters (4.1%-10.3%, ES: 0.42-0.68) in the T2DM group compared with the control group. However, TBS was lower in the T2DM group compared to the control group (-14.7%, ES: 1.18). In addition, sex (β = 0.272 to 0.316) and body mass index (BMI) (β = 0.236 to 0.455) were the most consistent and positive predictors of aBMD (p ≤ 0.01). BMI and P1NP were negative predictors of TBS (β = -0.530 and -0.254, respectively, p ≤ 0.01), while CTX was a positive one (β = 0.226, p=0.02). Finally, BMI was consistently the strongest positive predictor of 3D-DXA parameters (β = 0.240 to 0.442, p<0.05).

CONCLUSION

Patients with T2DM present higher bone mass measured both by conventional DXA and 3D-DXA, suggesting that 3D-DXA technology is not capable of identifying alterations in bone structure in this population. Moreover, BMI was the most consistent determinant in all bone outcomes.

Comparison of quantitative ultrasound of calcaneus and dual energy X-ray absorptiometry in measuring bone density and predicting fractures in patients with diabetic polyneuropathy: A prospective cohort study

AIMS

Compare quantitative ultrasound (QUS) of calcaneus and dual energy X-ray absorptiometry (DXA) as measurements of bone density, calculate 20-year fracture incidence in patients with T1DM and T2DM and multiple complications, and compare the methods' predictive ability.

METHODS

Sixty-two hospital foot clinic patients with T1DM or T2DM and complications were followed (1995-2015; 610 person-years). Clinical assessments and QUS of calcaneus were performed on all at inclusion and DXA of the spine and femoral neck on a subgroup (n = 34). Fracture incidence was assessed at follow-up and compared to incidence in the general population. We evaluated the correlation between QUS of calcaneus and DXA (Pearson's correlation test) and the association between bone density and fracture incidence at follow-up (logistic regression).

RESULTS

Bone density (QUS of calcaneus) correlated with hip bone density (DXA). Incidence of all fractures (30/62 patients; 48%) and hip fractures (6/62 patients; 10%) was higher in patients than the general population. Twelve (19%) experienced foot fracture. QUS of calcaneus predicted hip, lower leg, and foot fractures; DXA did not.

CONCLUSIONS

Because QUS of calcaneus predicted fractures in patients with diabetes and multiple complications, it seems appropriate to test QUS of calcaneus as a fracture risk predictor in primary care.

Assessing hip fracture risk in type-2 diabetic patients using CT-based autonomous finite element methods : a feasibility study

AIMS

Type 2 diabetes mellitus (T2DM) impairs bone strength and is a significant risk factor for hip fracture, yet currently there is no reliable tool to assess this risk. Most risk stratification methods rely on bone mineral density, which is not impaired by diabetes, rendering current tests ineffective. CT-based finite element analysis (CTFEA) calculates the mechanical response of bone to load and uses the yield strain, which is reduced in T2DM patients, to measure bone strength. The purpose of this feasibility study was to examine whether CTFEA could be used to assess the hip fracture risk for T2DM patients.

METHODS

A retrospective cohort study was undertaken using autonomous CTFEA performed on existing abdominal or pelvic CT data comparing two groups of T2DM patients: a study group of 27 patients who had sustained a hip fracture within the year following the CT scan and a control group of 24 patients who did not have a hip fracture within one year. The main outcome of the CTFEA is a novel measure of hip bone strength termed the Hip Strength Score (HSS).

RESULTS

The HSS was significantly lower in the study group (1.76 (SD 0.46)) than in the control group (2.31 (SD 0.74); p = 0.002). A multivariate model showed the odds of having a hip fracture were 17 times greater in patients who had an HSS ≤ 2.2. The CTFEA has a sensitivity of 89%, a specificity of 76%, and an area under the curve of 0.90.

CONCLUSION

This preliminary study demonstrates the feasibility of using a CTFEA-based bone strength parameter to assess hip fracture risk in a population of T2DM patients. Cite this article: Bone Joint J 2021;103-B(9):1497-1504.

Research trends in trabecular bone score: A bibliometric review from 2008 to 2019

Objective:

Trabecular bone score (TBS) is a novel index for assessing bone microarchitecture quality. No bibliometric reviews to date have yet explored the literature of TBS. Therefore, this study aimed to provide a bibliometric review on the trends of research publications on TBS indexed in the Science Citation Index Expanded and the Social Sciences Citation Index from 2008 to 2019.

Materials and Methods:

Using the Science Citation Index Expanded and the Social Sciences Citation Index, articles designated as original articles or review articles were searched using the keyword “trabecular bone score.” The retrieved articles were analyzed using Histcite 12.03.17 and VOSviewer v. 1.6.15 to identify top authors, journals, countries, and occurrence of keywords.

Results:

A total of 430 original and review articles on TBS published between 2008 and 2019 were identified. The number of articles increased steadily from 2008 to 2019, reaching 80 articles in 2019 alone. The United States of America, Switzerland, and France were the countries with the highest output of publications. The journal Osteoporosis International published the largest number of articles on TBS. Analysis of co-occurrence of author-supplied keywords revealed four clusters, with TBS, bone mineral density, and osteoporosis as the most prominent keywords.

Conclusion:

This bibliometric study on TBS published between 2008 and 2019 revealed the collaborative network of countries and the highly published journals and authors. Co-occurrence of keywords also revealed clusters of research hotspots, which could contribute to the understanding of the current state of TBS research and the identification of research gap.

Femur absorptiometry changes determined by X-ray image segmentation in mice under experimental diabetes and ovariectomy

AIM

The aim of the present work was to determine if both ovariectomy (OVX) and type 2 diabetes mellitus (T2DM) can change X-ray absorptiometry until reach the osteoporosis condition.

RESULTS

The segmentation allowed us to quantitatively determine the X-ray absorption in the femurs of mice subjected to OVX, T2DM and both pathologies together.

CONCLUSIONS

The test subjects suffering from the mentioned pathologies separately or together, did not reach the osteoporosis condition when they were 30 weeks old.

The risk of hip fractures in individuals over 50 years old with prediabetes and type 2 diabetes - A longitudinal nationwide population-based study

BACKGROUND

The present study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and hip fractures using a large-scale nationwide population-based cohort that is representative of the Republic of Korea. We determined the risks of hip fractures in individuals with prediabetes and T2DM with different diabetes durations, and compared them with the risks of hip fractures in individuals without T2DM.

METHODS

A total of 5,761,785 subjects over 50 years old who underwent the National Health Insurance Service medical checkup in 2009-2010 were included. Subjects were classified into 5 groups based on the diabetes status; Normal, Prediabetes, Newly-diagnosed T2DM, T2DM less than 5 years, and T2DM more than 5 years. They were followed from the date of the medical checkup to the end of 2016. The endpoint was a new development of hip fracture during follow-up. The hazard ratios (HRs) and 95% confidence intervals (CIs) of hip fractures for each group were analyzed using Cox proportional hazard regression models after adjusting for age, sex, smoking, alcohol drinking, regular exercise, body mass index, hypertension, dyslipidemia, and chronic kidney disease.

RESULTS

The HRs of hip fractures were 1 in the Normal group, 1.032 (95% CI: 1.009, 1.056) in the Prediabetes group, 1.168 (95% CI: 1.113, 1.225) in the Newly-diagnosed T2DM2, 1.543 (95% CI: 1.495, 1.592) in the T2DM less than 5 years and 2.105 (95% CI: 2.054, 2.157) in the T2DM more than 5 years. The secular trend of the HRs of hip fractures according to the duration of T2DM was statistically significant (P < .001). Subgroup analyses also showed the same increasing pattern of the HRs of hip fractures according to the duration of T2DM in both sexes and all age groups (50-64 years, 65-74 years, over 75 years).

CONCLUSIONS

In summary, this large-scale, retrospective, longitudinal, nationwide population-based cohort study of 5,761,785 subjects demonstrated that the risks of hip fractures started to increase in prediabetes and was associated linearly with the duration of T2DM. The secular trend of risks of hip fractures according to the duration of T2DM was consistent in both sexes and all age groups.

Impact microindentation in men with impaired fasting glucose and type 2 diabetes

BACKGROUND

Individuals with type 2 diabetes (T2DM) are at increased fracture risk, with bone mineral density (BMD) measurements underestimating risk. Impact microindentation (IMI), a technique that measures bone microindentation distances, expressed as bone material strength index (BMSi), may improve fracture risk estimation in individuals with T2DM. This study describes the relationship between BMSi and glycaemia status in men and makes a comparison with bone measures from dual energy X-ray absorptiometry (DXA).

MATERIAL AND METHODS

Participants were 340 men aged 33-96 yr from the Geelong Osteoporosis Study. Impaired fasting glucose (IFG) was defined using fasting plasma glucose (FPG) between 5.5 and 6.9 mmol/L. Diabetes was defined as FPG ≥ 7.0 mmol/L, use of antihyperglycemic medication and/or self-report. Two participants with type 1 diabetes were excluded. BMSi was measured using an OsteoProbe. Femoral neck (FNBMD) and lumbar spine (LSBMD) were measured using DXA (Lunar Prodigy) and trabecular bone score (TBS) was calculated (TBS iNsight Version 2.2). Using linear regression techniques, the relationship between glycaemia status and BMSi was evaluated, adjusting for other potential confounders (including lifestyle factors, clinical measurements and FNBMD). Glycaemia status was also considered as a binary variable (T2DM vs normoglycaemia and IFG).

RESULTS

There were 234 (68.8%) men with normoglycaemia, 59 (17.4%) with IFG and 47 (13.8%) with diabetes. When considering glycaemia status as a binary variable, men with T2DM had lower mean BMSi compared to those without T2DM (normoglycaemia and IFG combined) (79.8; 95%CI 77.0-82.6 vs 83.0; 82.2-83.8 p = 0.043) and this difference in BMSi was independent of FNBMD. No differences were observed for either FNBMD or LSBMD; however, TBS was lower (1.177; 1.121-1.233 vs 1.256; 1.240-1.272, p = 0.015, independent of FNBMD). For glycaemia status considered in three groups, there were no differences in mean BMSi values between men with normoglycaemia, IFG and T2DM (82.9 (95%CI 82.0-83.8), 83.5 (81.8-85.2) and 79.8 (77.0-82.6), respectively; ANCOVA, p = 0.104).

CONCLUSIONS

Measures reflecting bone material properties and microarchitecture (BMSi and TBS) might be better than measures of bone mass (BMD) in identifying individuals with T2DM at risk of fracture.

Use of Bone Health Evaluation in Orthopedic Surgery: 2019 ISCD Official Position

This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown.

Frailty and Risk of Fractures in Patients With Type 2 Diabetes

OBJECTIVE

We aimed to explore whether frailty was associated with fracture risk and whether frailty could modify the propensity of type 2 diabetes toward increased risk of fractures.

RESEARCH DESIGN AND METHODS

Data were from a prospective cohort study. Our primary outcome was time to the first incident clinical fragility fracture; secondary outcomes included time to hip fracture and to clinical spine fracture. Frailty status was measured by a Frailty Index (FI) of deficit accumulation. The Cox model incorporating an interaction term (frailty × diabetes) was used for analyses.

RESULTS

The analysis included 3,149 (70% women) participants; 138 (60% women) had diabetes. Higher bone mineral density and FI were observed in participants with diabetes compared with control subjects. A significant relationship between the FI and the risk of incident fragility fractures was found, with a hazard ratio (HR) of 1.02 (95% CI 1.01-1.03) and 1.19 (95% CI 1.10-1.33) for per-0.01 and per-0.10 FI increase, respectively. The interaction was also statistically significant (P = 0.018). The HR for per-0.1 increase in the FI was 1.33 for participants with diabetes and 1.19 for those without diabetes if combining the estimate for the FI itself with the estimate from the interaction term. No evidence of interaction between frailty and diabetes was found for risk of hip and clinical spine fractures.

CONCLUSIONS

Participants with type 2 diabetes were significantly frailer than individuals without diabetes. Frailty increases the risk of fragility fracture and enhances the effect of diabetes on fragility fractures. Particular attention should be paid to diabetes as a risk factor for fragility fractures in those who are frail.

Epidemiology and correlates of osteoporotic fractures among type 2 diabetic patients

This study analyzed data on 87,224 osteoporotic patients with up to 18 years of computerized medical history. Patients with osteoporosis and type 2 diabetes had higher bone density yet more fractures than non-diabetic osteoporotic patients. Fracture incidence among the diabetic patients was associated with retinopathy and cardiovascular disease, but not with diabetes duration.

PURPOSE

Little is known about the association between type 2 diabetes mellitus (T2DM) and fragility fractures or the mechanism(s) involved. We examined fracture correlates among T2DM patients with osteoporosis.

METHODS

We used electronic health records of an osteoporosis (OP) registry cross-linked with a diabetes registry of a large payer provider healthcare organization in Israel. A cross-sectional analysis compared osteoporosis patients with and without T2DM, and a longitudinal Cox proportional hazard regression was used to identify incident fracture correlates.

RESULTS

As of December 2015 a total of 87,224 current OP patients were identified, of whom 15,700 (18%) had T2DM. The T2DM OP patients were characterized by older age (mean 74.6 vs. 69.5), more males (20.3 vs. 14.0%), and a higher rate of chronic comorbidities compared to OP without diabetes. All major OP fractures (hip, spine, humerus, and forearm) were significantly more prevalent among T2DM OP patients (44 vs. 32%), with an overall age-standardized ratio of 1.22 (95% CI 1.19 to 1.25) and 1.15 (95% CI 1.10 to 1.21) for females and males respectively. The average T-scores were higher (femur neck - 1.8 vs. - 1.9, total hip - 1.2 vs. - 1.6, and vertebrae - 1.3 vs. - 1.7) for the T2DM OP patients compared to the non-T2DM OP patients. Among women with coexisting T2DM and osteoporosis (n = 10,812), fracture incidence was significantly associated with retinopathy (HR = 1.24, 95% CI 1.05 to 1.47) and cardiovascular disease (HR = 1.22, 95% CI 1.10 to 1.36) after controlling for age, bone mineral density T-score, rheumatoid arthritis, glucocorticoids, alcohol, and smoking).

CONCLUSION

This large population-based study confirms the higher fracture risk of osteoporotic patients with T2DM, as compared to osteoporotic patients without T2DM, despite higher bone mineral density levels. The presence of micro- and macrovascular disease appears to increase this risk.

Sarcopenia: a chronic complication of type 2 diabetes mellitus

BACKGROUND

Diabetics are at increased risk for impaired mobility and strength, frequently related to the disease control. Sarcopenia is the reduction of muscle mass associated with the decrease in muscle strength and/or performance, resulting in worse morbidity in chronic diseases.

METHODS

The objectives of this paper was to assess the prevalence of sarcopenia in patients with type 2 diabetes mellitus (T2DM) and determine its association with diabetes characteristics, progression, and complications, as well as changes in bone mineral density. The sample consisted of patients with T2DM followed at the outpatient clinics of the Serviço de Endocrinologia e Metabologia do Hospital de Clínicas da Universidade Federal do Paraná, from March to August 2016. Participants were men and women above 18 years with T2DM diagnosed at least 1 year earlier. Individuals with chronic diseases, users of any drug that modifies body composition, patients with body mass index (BMI) > 35 or < 18 kg/m², and users of illicit drugs or hormonal or nutritional supplementation were excluded. The selected patients answered questionnaires about demographics, eating habits, and disease characteristics, and performed a bone densitometry exam in a dual energy absorptiometry (total body; spine and femur (total and neck)), a handgrip test by manual dynamometer, and an evaluation of the abdominal circumference (AC). The medical records were reviewed seeking diabetes data and laboratory test results. Patients were matched for sex, age, and race with healthy controls [Control Group (CG)]. The diagnosis of sarcopenia was conducted according to the criteria of the Foundation for National Institute of Health.

RESULTS

The final sample consisted of 83 patients in the DG and 83 in the CG. The DG had higher BMI, WC, past history of fractures and lower calcium and healthy diet intake (p < 0.005), compared to the CG. The DG presented a higher frequency of abnormal BMD (osteopenia in 45 (53%), and osteoporosis in 14 (19%)) and comorbidities than the CG (p < 0.005). Pre-sarcopenia was not different between groups, but muscle weakness was present in 25 diabetics (18 women) and only in 5 controls (4 men) (p = 0.00036). Sarcopenia was diagnosed in 13 (16.2%) patients in the DG and 2 (2.4%) in the CG (p = 0.01168). Pre-sarcopenia and sarcopenia were associated with altered BMD (p < 0.005), with no association with diabetes duration or control. Body mass index and osteoporosis increased the likelihood to have sarcopenia, but hypertension and healthy diet decreased it.

CONCLUSION

The DG had altered BMD associated with worse glycemic control, and a higher prevalence of sarcopenia, suggesting the need to look for their presence in diabetics.