The association of diabetes status and bone mineral density among US adults: evidence from NHANES 2005-2018

An update on bone in diabetes

PURPOSE OF REVIEW

As the prevalence of diabetes mellitus (DM) increases due to urbanization, aging populations, and lifestyle changes, it is crucial to understand the mechanisms, diagnosis, and treatment of diabetes-related bone disorders. This review highlights recent advancements in the field and explores their implications for clinical practice and research.

RECENT FINDINGS

Recent studies have elucidated the complex interplay between diabetes and bone health, emphasizing the roles of advanced glycation end-products (AGEs), inflammation, oxidative stress, senescence, and molecular signaling pathways such as Wnt, mammalian target of rapamycin (mTOR), and exosome-mediated mechanisms. Key findings highlight the significance of bone marrow adipose tissue (BMAT) in bone metabolism and the impact of sarcopenia on fracture risk. Novel diagnostic tools, including miRNA biomarkers and emerging therapeutic strategies like exosome-based therapies and glycogen synthase kinase 3 beta (GSK3β) inhibitors, offer promising opportunities for improving bone health in diabetic patients.

SUMMARY

The findings underscore the need for integrated strategies for managing diabetes-related bone complications. Clinicians should prioritize early screening, lifestyle interventions, and personalized pharmacological treatments to mitigate fracture risk and improve bone health in diabetic patients. Future research should focus on optimizing diagnostic tools and developing targeted therapies to address the unique challenges of bone disorders related to diabetes.

Association of the weight-adjusted waist index with mortality in osteoporotic patients

INTRODUCTION

The prevalence of osteoporosis (OP) is steadily rising, leading to a higher risk of mortality. This study assessed the impact of the Weight-Adjusted Waist Index (WWI) on osteoporosis-related mortality.

MATERIALS AND METHODS

Data from NHANES 2005-2010, 2013-2014, and 2017-2018 were analyzed to evaluate the relationship between WWI and mortality in osteoporotic patients using weighted proportional hazards model and Kaplan-Meier survival analysis. A subgroup analysis was performed to ensure the stability of the findings.

RESULTS

The study included 1324 participants. The findings indicated a positive correlation between WWI and OP (OR 1.65, 95% CI 1.45-1.89). Among patients with OP, WWI showed a positive association with all-cause mortality (HR 1.28, 95% CI 1.10-1.48). There was no observed correlation between varying WWI levels and mortality due to cardiovascular disease or cancer.

CONCLUSIONS

Maintaining a lower WWI is associated with a reduced risk of all-cause mortality among individuals with OP.

Fractured FRAX: Nurses' role in reckoning with racism in international osteoporosis fracture risk calculations

AIM

This paper will examine racism's role in calculating fracture risk via the use of race- and ethnicity-based calculations and offer guidance for nurses to mitigate the risk of further exacerbating race-based inequities in fracture care.

BACKGROUND

Using race adjustments in fracture risk calculation, such as in the FRAX, reflects the history of systemic racism in nursing and medicine, particularly in screening for and treating osteoporosis. Osteoporosis-related fractures, which result in increased costs, disability, and death, are a public health problem.

SOURCES OF EVIDENCE

The critique examines genetic and sociohistorical evidence to illuminate the fallacy that race has biological underpinnings and outline the implications of using race in fracture risk assessment.

DISCUSSION

Race-based risk calculation, including assessing fracture risk, is one of the mechanisms by which the medical and healthcare sectors perpetuate systemic racism.

IMPLICATIONS FOR NURSING PRACTICE AND POLICY

Nurses are called to action to address the contributing role of race-based algorithms, such as the FRAX, to unequal treatment. Nurses should advocate for the removal of race in these clinical decision-making tools and case studies. Additionally, nurses should advocate for their replacement with better tools that do not use race but rather measures of structural racism to calculate risk. Policy guidance should be issued so that race, a sociohistorical tool of categorization to preserve power structures, should no longer be used as an approximation of other more relevant and precise risk factors for fractures or other diseases.

CONCLUSION

Nurses are critical in cultivating and implementing antiracist approaches to remediate health inequities in screening and treatment of osteoporosis and other preventable diseases.

Investigating the triglyceride-glucose index in postmenopausal osteoporosis

OBJECTIVE

This retrospective study aims to assess the association of the triglyceride-glucose index (TyG index) with postmenopausal osteoporosis and investigate longitudinal changes in TyG index levels in relation to osteoporosis risk.

METHODS

Out of 704 women, after excluding those with osteopenia, a total of 517 patients who met the inclusion criteria were included. Participants were categorized based on T-scores derived from lumbar spine dual-energy X-ray absorptiometry scans. Demographic data, biochemical parameters and TyG index levels were analyzed. Logistic regression, correlation analysis and receiver operating characteristic (ROC) curve analysis were employed for statistical evaluation.

RESULTS

The osteoporosis group (n = 254) exhibited significantly higher TyG index and triglyceride levels compared to controls (n = 263). Longitudinal analysis revealed significant increases in TyG index levels among women developing osteoporosis over time. ROC analysis demonstrated the TyG index's accuracy for osteoporosis (first TyG area under the curve [AUC]: 0.767, second TyG AUC: 0.818, p < 0.001). Regression analyses identified the TyG index as a significant factor associated with osteoporosis (odds ratio: 39.468, 95% confidence interval: 12.884-120.903, p < 0.001).

CONCLUSIONS

The TyG index emerges as a valuable indicator for postmenopausal osteoporosis. These results emphasize the need for integrating metabolic health indicators into osteoporosis management strategies, warranting further research into targeted interventions.

The association between serum folate and elderly diastolic hypertension: results from the NHANES (2007-2018)

AIM

To explore the association between serum folate concentration and the prevalence of elderly diastolic hypertension. This study aims to identify potential relationships that could inform further research into the mechanisms underlying hypertension management.

METHODS

Data from six NHANES cycles (2007-2008, 2009-2010, 2011-2012, 2013-2014, 2015-2016, and 2017-2018) were analysed for individuals aged over 60. Weighted logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup and restricted cubic spline (RCS) regression explored the serum folate concentration and elderly diastolic hypertension relationship.

RESULTS

This study included 9,419 participants (4,734 females and 4,685 males) with a mean age of 70.0 ± 7.0 years. Among them, 360 were diagnosed with diastolic hypertension. In the fully adjusted model, there was a negative correlation between serum folate concentration and the prevalence of diastolic hypertension (OR 0.65; 95% CI: 0.52-0.82). When serum folate concentration levels were divided into quartiles (in μg/dL), the ORs for diastolic hypertension corresponding to Q2 (1.29-1.98), Q3 (1.99-3.08), and Q4 (3.09-5.56) levels compared to Q1 (0.18-1.28) were 1.41 (95% CI: 0.60-3.33), 0.48(95% CI: 0.20-1.16), and 0.35 (95% CI: 0.16-0.74), respectively, with a P for trend <.05. Restricted cubic spline plots showed a negative correlation between serum folate concentration and the prevalence of diastolic hypertension (non-linearity: p = .495). Subgroup analysis indicated that the negative correlation between serum folate concentration and the prevalence of diastolic hypertension was more significant in female participants (interaction p = .009).

CONCLUSION

Higher serum folate concentration is associated with a lower prevalence of diastolic hypertension in the elderly.

Weight change, variability, and trajectories and risk of hip fracture among older adults with dysglycemia: the cardiovascular health study

Type 2 diabetes mellitus and lower weight are both associated with osteoporotic fractures, but the roles of variability and trajectory are less clear. The associations of these factors among older adults with dysglycemia, who are at highest risk of fracture, with fracture risk and BMD remain uncertain. We followed 775 men and 1080 women from the Cardiovascular Health Study (mean age 77.4 years) with abnormal oral glucose tolerance testing in 1989-1990. We measured their weights yearly through 1994-1995 and derived intra-individual mean weight, weight slope, and weight variability. We also used growth mixture modeling to derive 4 latent BMI trajectories over time. We used Cox proportional hazards models to calculate hazard ratios (HRs) and 95% CI for subsequent hip fracture through 2015 and linear regression models to estimate cross-sectional associations with BMD of the hip. Each 10 kg higher mean weight was associated with a lower risk of subsequent hip fracture overall (HR 0.81; CI, 0.70-0.94) and among women (HR 0.76; CI, 0.64-0.91) and with higher BMD (p <.001). Higher weight variability was directly associated with incident hip fracture among women (HR 1.18; CI, 1.03-1.35). Compared with a stable trajectory, a "progressive overweight" trajectory was associated with lower risk of hip fracture (HR 0.66; CI, 0.44-0.99). An uncommon trajectory of "accelerating obesity" was associated with higher BMD. Among older adults with dysglycemia at high risk for fracture, lower mean weight is associated with higher fracture risk, but variability and trajectory may also contribute. These results highlight the complex effects of weight in older age.

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.

Links among Obesity, Type 2 Diabetes Mellitus, and Osteoporosis: Bone as a Target

Obesity, type 2 diabetes mellitus (T2DM) and osteoporosis are serious diseases with an ever-increasing incidence that quite often coexist, especially in the elderly. Individuals with obesity and T2DM have impaired bone quality and an elevated risk of fragility fractures, despite higher and/or unchanged bone mineral density (BMD). The effect of obesity on fracture risk is site-specific, with reduced risk for several fractures (e.g., hip, pelvis, and wrist) and increased risk for others (e.g., humerus, ankle, upper leg, elbow, vertebrae, and rib). Patients with T2DM have a greater risk of hip, upper leg, foot, humerus, and total fractures. A chronic pro-inflammatory state, increased risk of falls, secondary complications, and pharmacotherapy can contribute to the pathophysiology of aforementioned fractures. Bisphosphonates and denosumab significantly reduced the risk of vertebral fractures in patients with both obesity and T2DM. Teriparatide significantly lowered non-vertebral fracture risk in T2DM subjects. It is important to recognize elevated fracture risk and osteoporosis in obese and T2DM patients, as they are currently considered low risk and tend to be underdiagnosed and undertreated. The implementation of better diagnostic tools, including trabecular bone score, lumbar spine BMD/body mass index (BMI) ratio, and microRNAs to predict bone fragility, could improve fracture prevention in this patient group.

L-shaped association between lean body mass to visceral fat mass ratio with hyperuricemia: a cross-sectional study

BACKGROUND

Insufficient attention has been given to examining the correlation between body composition and hyperuricemia, leading to inconsistent findings. The primary objective of this research is to explore the association between lean body mass index (LMI), visceral fat mass index (VFMI), and hyperuricemia. A specific emphasis will be placed on assessing the link between the ratio of lean body mass to visceral fat mass (LMI/VFMI) and hyperuricemia.

METHODS

The present study employed a cross-sectional design and involved a total of 9,646 individuals who participated in the National Health and Nutrition Examination Survey (NHANES). To explore the associations among the variables, logistic and linear regressions were employed. Additionally, subgroup analyses and sensitivity analyses were conducted based on various characteristics.

RESULTS

The results showed that LMI was positively associated with hyperuricemia (for Per-SD: OR = 1.88, 95%CI: 1.75, 2.01; for quartiles [Q4:Q1]: OR = 5.37, 95%CI: 4.31, 6.69). Meanwhile, VFMI showed a positive association with hyperuricemia (for Per-SD: OR = 2.02, 95%CI: 1.88, 2.16; for quartiles [Q4:Q1]: OR =8.37, 95%CI: 6.70, 10.47). When considering the effects of In LMI/VFMI, an L-shaped negative association with hyperuricemia was observed (for Per-SD: OR = 0.45, 95%CI: 0.42, 0.49; for quartiles [Q4:Q1]: OR = 0.16, 95%CI: 0.13, 0.20). Subgroup and sensitivity analyses demonstrated the robustness of this association across different subgroups. Additionally, the segmented regression analysis indicated a saturation effect of 5.64 for the In LMI/VFMI with hyperuricemia (OR = 0.20, 95%CI: 0.17, 0.24). For every 2.72-fold increase of In LMI/VFMI, the risk of hyperuricemia was reduced by 80%.

CONCLUSION

The LMI/VFMI ratio is non-linearly associated with serum uric acid. Whether this association is causal needs to be confirmed in further longitudinal studies or Mendelian randomization.

Use of noninvasive imaging to identify causes of skeletal fragility in adults with diabetes: a review

Diabetes, a disease marked by consistent high blood glucose levels, is associated with various complications such as neuropathy, nephropathy, retinopathy, and cardiovascular disease. Notably, skeletal fragility has emerged as a significant complication in both type 1 (T1D) and type 2 (T2D) diabetic patients. This review examines noninvasive imaging studies that evaluate skeletal outcomes in adults with T1D and T2D, emphasizing distinct skeletal phenotypes linked with each condition and pinpointing gaps in understanding bone health in diabetes. Although traditional DXA-BMD does not fully capture the increased fracture risk in diabetes, recent techniques such as quantitative computed tomography, peripheral quantitative computed tomography, high-resolution quantitative computed tomography, and MRI provide insights into 3D bone density, microstructure, and strength. Notably, existing studies present heterogeneous results possibly due to variations in design, outcome measures, and potential misclassification between T1D and T2D. Thus, the true nature of diabetic skeletal fragility is yet to be fully understood. As T1D and T2D are diverse conditions with heterogeneous subtypes, future research should delve deeper into skeletal fragility by diabetic phenotypes and focus on longitudinal studies in larger, diverse cohorts to elucidate the complex influence of T1D and T2D on bone health and fracture outcomes.

The relationship between weight-adjusted-waist index and total bone mineral density in adults aged 20-59

Introduction

According to reports, obesity has a significant impact on bone health. And the weight-adjusted-waist index (WWI), superior to BMI and waist circumference (WC), is a new obesity indicator arising in recent years. This research investigated the relationship between WWI and total bone mineral density (BMD) for adults aged 20 to 59.

Methods

Using data from the 2011-2018 NHANES, we looked into the independent link between WWI and total BMD as well as its nonlinearity using weighted multiple linear regression and smooth curve fitting. Two-stage linear regression models were employed to calculate the threshold effects. There were additional subgroup analyses and testing for interactions.

Results

Multiple linear regression studies on a total of 10,372 individuals showed a significant inverse link between WWI and total BMD in adults between 20 and 59 [β = -0.04, 95% CI: (-0.04, -0.03), P<0.0001]. And smoking, race, and chronic kidney disease (CKD) had no significant effect on this negative connection (P for interaction >0.05). In addition, we found a nonlinear relationship between WWI and total BMD in diabetic and CKD patients, for which the saturation point was 11.38 cm/√kg in the CKD patient group and 10.29 cm/√kg in the diabetic patient group.

Conclusion

Our analysis demonstrated a significant inverse association between WWI and total BMD in adults aged 20-59.

Association between triglyceride-glucose index and bone mineral density in US adults: a cross sectional study

OBJECTIVE

Disorders in glucose and lipid metabolism have been shown to exert an influence on bone metabolism. The TyG index, which combines measures of glucose and triglycerides, provides insights into the overall metabolic status. However, the investigation of concurrent disturbances in glucose and lipid metabolism and their specific implications for bone metabolism remains limited in the existing research literature. This study aimed to explore the correlation between the TyG index and bone mineral density (BMD) in US adults.

METHODS

In the National Health and Nutrition Examination Survey (NHANES), subjects were classified based on the TyG index into four groups (< 7.97, 7.97-8.39, 8.39-8.85, > 8.86). Linear regression analysis was conducted to determine the β value and 95% confidence interval (CI). Four multivariable models were constructed. Restricted cubic spline analyses and piecewise linear regression were employed to identify the association between the BMD and TyG index. An analysis of subgroups was also conducted in this study.

RESULTS

Significant variations in related characteristics were found among the US adult population, who were distributed into four groups based on the quartiles of the TyG index. A negative correlation between the TyG index and lumbar spine BMD was observed. In the multi-adjusted models, compared to Q1 of the TyG index, the β for Q4 of the TyG index for lumbar spine BMD was [β = - 0.008, 95% CI (- 0.017, 0)] in US adults. The association between the TyG index and lumbar spine BMD was found to be nonlinear (all nonlinear p < 0.001), with a threshold value based on restricted cubic spline analyses. Above the threshold point, the β for lumbar spine BMD was - 0.042 (95% CI, - 0.059, - 0.024). Below the threshold points, no significant difference was observed (p > 0.05). No significant interactions were observed among subgroups based on age, gender, presence of diabetes, BMI, and use of antidiabetic and antihyperlipidemic agents. Similar patterns of association were observed in total and subtotal bone density.

CONCLUSIONS

This study identified a nonlinear association between the TyG index and BMD in the US population. Furthermore, an increased level of the TyG index may indicate a higher risk of osteoporosis among US adults. These findings highlight the importance of considering glucose and lipid metabolism disturbances in understanding bone health and the potential for developing preventive strategies for osteoporosis.

Association between lean body mass to visceral fat mass ratio and bone mineral density in United States population: a cross-sectional study

BACKGROUND

Studies have explored the correlation between body composition and bone mineral density (BMD), but there has yet to be a consensus. Thus, the present study aims to comprehensively investigate the association between lean body mass, adipose tissue, and BMD.

METHODS

We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) (2011-2018) with 11,227 subjects. Multiple linear regression, smoothed curve fitting, threshold, and saturation effect analysis were used to explore the association between lean body mass, visceral fat mass, and BMD. Also, we used the lean body mass to visceral fat mass ratio (Log LM/VFM) as a proxy variable to analyze its association with BMD alone.

RESULTS

After adjusting for potential confounding factors, the results showed a positive correlation between lean mass and total BMD (for continuous: β = 0.078, P < 0.001; for quartile: β = 0.138, P < 0.001), while visceral fat mass was negatively correlated (for continuous: β = -0.027, P < 0.001; for quartile: β = -0.065, P < 0.001). A positive correlation was observed when the alternative variable Log LM/VFM was analyzed separately for its association with BMD (for continuous: β = 0.034, P < 0.001; for quartile: β = 0.084, P < 0.001). In addition, subgroup analyses for gender, age, body mass index, hypertension, and diabetes showed that all subgroups except the diabetes subgroup showed a substantial degree of robustness (P < 0.05). The smoothed curve fitting showed a nonlinear relationship between Log LM/VFM and BMD, and there was a threshold effect with a critical value of 2.60.

CONCLUSION

Maintaining a proper ratio of lean body mass and visceral fat mass is beneficial for increasing BMD.

Bone Mineral Density Evaluation Among Type 2 Diabetic Patients in Rural Haryana, India: An Analytical Cross-Sectional Study

Background and objective Diabetes is one of the most prevalent diseases globally, affecting almost all organ systems. The relationship between type 2 diabetes mellitus (T2DM) and bone mineral density (BMD) has been a matter of controversy, and data from developing countries in this regard is highly scarce. Early detection of low BMD in diabetic patients will help prevent further bone loss and risk of fragility fracture. In this study, we aimed to assess the effect of T2DM on BMD among the rural population of Haryana, India. Materials and methods This was a cross-sectional study involving 850 patients between 25 and 60 years of age, including 425 diabetic and 425 non-diabetic subjects (as controls). Calcaneus BMD was measured by using quantitative ultrasound (QUS), and the data were compared against matched parameters in both groups. Results The mean age of diabetics was 42.21 ± 10.5 years and that of non-diabetics was 42.18 ± 10.4 years. The mean BMI was 27.8 ± 4.17 kg/m2 in diabetics and 21.6 ± 3.32 kg/m2 in the non-diabetic control group. BMD values significantly differed between the groups: -4.3 ± 1.23 vs. -2.6 ± 0.34 in diabetics and non-diabetics, respectively (p=0.002). Conclusion A significant difference in BMD was observed between the diabetic and non-diabetic groups. Based on our findings, We recommend that all type 2 diabetics be screened for osteoporosis so that this silent bone loss can be detected in the early phase itself and appropriate preventive measures can be promptly initiated.

The complex pathophysiology of bone fragility in obesity and type 2 diabetes mellitus: therapeutic targets to promote osteogenesis

Fractures associated with Type2 diabetes (T2DM) are major public health concerns in an increasingly obese and aging population. Patients with obesity or T2DM have normal or better than normal bone mineral density but at an increased risk for fractures. Hence it is crucial to understand the pathophysiology and mechanism of how T2DM and obesity result in altered bone physiology leading to increased fracture risk. Although enhanced osteoclast mediated bone resorption has been reported for these patients, the most notable observation among patients with T2DM is the reduction in bone formation from mostly dysfunction in osteoblast differentiation and survival. Studies have shown that obesity and T2DM are associated with increased adipogenesis which is most likely at the expense of reduced osteogenesis and myogenesis considering that adipocytes, osteoblasts, and myoblasts originate from the same progenitor cells. Furthermore, emerging data point to an inter-relationship between bone and metabolic homeostasis suggesting that these physiologic processes could be under the control of common regulatory pathways. Thus, this review aims to explore the complex mechanisms involved in lineage differentiation and their effect on bone pathophysiology in patients with obesity and T2DM along with an examination of potential novel pharmacological targets or a re-evaluation of existing drugs to improve bone homeostasis.