Osteoporosis in Diabetics By Dr Richard Nabhan Consulant Physician,Cardiologist & Diabetologist Fellow of Royal College of Physician ( London) Osteoporosis Club Symposium 29 Oct. 2009

Osteoporosis A major public threat for more than 28 million Americans. 80 % are women. One in 2 women and One in 8 men over 50 will have an osteoporosis related fracture. The estimated cost for osteoporotic and associated fractures is 38 million a day!

What is it? A disease in which bones become fragile and more likely to break. Breaks usually occur in the hip, spine and wrist.

Risk Factors Certain people are more likely to develop this disease than others. Female Thin and/or small frame Advanced age Family history of osteoporosis Post menopause

Risk Factors Anorexia nervosa or bulimia Diet low in calcium Use of certain medications Low testosterone levels in men An inactive lifestyle Cigarette smoking Excessive use of alcohol Being Asian or Caucasian

Are your bones healthy? Normal bone Osteoporosis

Bone Health Bones are living tissue, they provide structural support, protect vital organs and store calcium. Until age 30, we store and build bone effectively. As part of the aging process, bones begin to break down faster than they are formed. Accelerates after menopause. Estrogen is the hormone that protects against bone loss.

Detection Bone Density Tests: Can detect osteoporosis before a fracture occurs. Predicts your chances of fracturing in the future. Determines your rate of bone loss and monitors the effects of treatment.

Bone Mass Density The National Osteoporosis Foundation Recommends you have a BDT if: You use medications that cause osteoporosis You have type I diabetes, liver disease, kidney disease or a family history You experience early menopause You’re postmenopausal over 50 and have at least one risk factor. You’re postmenopausal over 65 and never had a test.

Diabetes Mellitus: Health Impact of the Disease Diabetes Blindness* Renal failure* Amputation* Life expectancy 5  to 10 yr Cardiovascular disease  2X to 4X * Diabetes is the no. 1 cause of renal failure, new cases of blindness, and nontraumatic amputations Nerve damage in 60% to 70% of patients 6th leading cause of death  OSTEOPOROSIS

Pathophysiology of Atherosclerosis Cerebrovascular Complications Peripheral Artery Disease Cardiac Complications Macro -vascular Complications of Diabetes

13 Micro -vascular Complications of Diabetes Nephropathy Neuropathy Retinopathy Diabetic Foot

14 Associations of Diabetes Hypertension Obesity Dyslipidemia Terrorists of Arteries

High risk factors for low bone mass-related fractures Aging (> years) Low body weight Weight loss Physical inactivity Corticosteroids Anticonvulsivants Primary hyperparathyroidism Anorexia nervosa Gastrectomy Pernicious anemia Prior osteoporotic fracture Diabetes Mellitus type 1

Moderate risk factors for low bone mass-related fractures Gender (female) Smoking (active) Low sunlight exposure Family history of osteoporotic fracture Surgical or early menopause Short fertile period, late menarche, no lactation Low calcium intake Hyperparathyroidism Hyperthyroidism Rheumatoid arthritis Diabetes Mellitus type 2

Risk factors for osteoporotic fractures in diabetes Risk for osteoporosis Poor glycemic control Nephropathy Neuropathy Diabetic diarrhea Due to diseases associated with diabetes Grave’s disease Celiac sprue Amenorrhea Delayed puberty Eating disorders Risks for falls Hypoglycemia Nocturia Poor vision Poor balance Orthostatic hypotension Impaired joint motility

( Osteoporosis is not a problem if you don’t fracture Osteoporosis Falls Fracture Fractures Bone fragility Falls risk Force of fall

Despite having a higher bone density, on average, the women with diabetes had a higher risk of hip and proximal humerus fractures. Other factors, associated with frailty and fracture, including falls, (and chronic complications of diabetes) did not account for the association between diabetes and fracture. Schwartz, J Clin Endocrinol Metab, 2001

Is diabetes associated with a decrease in bone strength that is not reflected in the measurement of BMD?

SecondaryHyperpara-thyroidism Hypo-magnesemia Decreased 1-25 Hydroxy- cholecalciferol Association with diabetes type 1: high rates of bone turnover Decreased IGF-I and Insulin Increased bone resorption Decreased bone formation

Peripheralinsulinresistance Impairedglucosetolerance Early diabetes Late diabetes Hyperinsulinemia Defective glucorecognition  -cell failure Association with diabetes type 2: low rates of bone turnover Decrease bone resorption Bone formation

A model of the interaction between Type 2 DM and bone quality impairment impairment in the secretion of cytokines and insulin-like growth factor AGE-modified collagen AGE on bone matrix alteration in the activities of collagen and bone cells Increased AGE-modified protein (nonenzymatic glycosylation) sarcopenia

Sarcopenia Age-related decline in muscle mass Result –Slow walking speed –Low physical activity –Decreased exercise tolerance –Low grip strength –Increased fall rates –Decreased bone strength Both males and females have age-related decline in muscle mass Sarcopenia affects women more –Lower baseline total muscle mass –Increased rate of loss of muscle mass in postmenopausal period Thus, women reach critical threshold of muscle mass loss and weakness more quickly

Has Fat a Protective Role for the Skeleton? “Pros & Cons”

Bone Cells Formation

Bone Homeostasis

Bone Is a Target For The Antidiabetic Compound Rosiglitazone Rzonca SO et al. Endocrinology, 2004 Control Rosiglitazone

Thiazolidinedione Use and Bone Loss in Older Diabetic Adults

Calcium Is needed for heart muscles, and nerves to function properly. Inadequate amounts contribute to osteoporosis. Appropriate calcium intake falls between 1000 and 1300 mg a day. To increase calcium: Consume calcium rich foods such as, low-fat milk, cheese, broccoli, and others. Calcium supplement, if dietary calcium consumption is inadequate

Vitamin D Is needed for your body to absorb calcium. Comes from 2 sources : the sun and Fortified dairy products, egg yolks, saltwater fish, and liver. Need IU a day.

Exercise Exercising regularly in childhood and adolescence can ensure that you will reach peak bone density. Need to participate in weight bearing exercise. For example, walking, dancing, jogging, stair climbing, racquet sports and hiking.

Prevention Building strong bones in childhood and adolescence is the best defense. A balanced diet rich in calcium and Vitamin D Weight bearing exercise A healthy lifestyle with no smoking or excessive alcohol intake. Bone density testing and medication when appropriate.

What’s next? We need to educate young women and teenagers about the risk of osteoporosis.

Conclusions The presence of osteoporosis in a diabetic patient is often not considered, but the risk of fragility fractures is higher. Besides optimal glycemic control, general recommendations regarding adequate dietary calcium and Vit.D intake, regular exercise, adequate treatment for diabetes and avoidance of other potential risk factors should be given.

Beware the terrorists of the Arteries Diabetes Hypertension Cholesterol Smoking Obesity – over weight Lack of exercise Unbalanced diet Lack of awareness Stress For a Healthier Community