How Diabetes impacts bone health

Diabetes is well known for bringing along complications such as nerve, cardiovascular, and visual damage. Nevertheless, its effects on the musculoskeletal system, and in particular on osteoporosis, are less often mentioned, but remain equally important. It has been established that both types of diabetes, Type 1 and Type 2 greatly predispose individuals to bone diseases such as osteoporosis and fragility fractures.



Mechanisms Linking Diabetes and Bone's Interactivity


1) Glycation of Bone Proteins: Chronic hyperglycemia results in an increased level of advanced glycation end products (AGEs) within bone. AGEs inhibit collagen quality, making bone fragility bones more fracture prone, hence diabetes mellitus complications can arise even when BMD is normal. Sometimes, it is referred to as “skeletal fragility.”


2) Hyperglycemia leading to osteoblast Dysfunction: Osteoblasts are the cells in charge of creating new bone. Diabetes creates high glucose concentration environments, which alter the osteoblasts allowing them limited abilities in growth, thus allowing imbalance in bone formation and resorption. Consequently, due to a lack of stimulation, the bone building process is not fully active and results in low bone turnover and poor quality of bone.


3) Insulin and Bone Metabolism: An anabolic hormone that promotes bone formation is insulin. Bone development and density are frequently reduced in type 1 diabetes due to insufficient insulin synthesis. On the other hand, insulin resistance, which is frequently developed by individuals with type 2 diabetes, has an indirect impact on bone health by decreasing the efficiency of insulin's bone-building effects.


4) Inflammation and Oxidative Stress: Diabetes frequently causes chronic inflammation, which raises oxidative stress and hinders bone remodeling. In diabetes, elevated cytokines such interleukins and TNF-α further interfere with the regular cycle of bone regeneration, hastening the loss of bone.


5) Neuropathy and Fall Risk: Up to 50% of diabetics have diabetic neuropathy, which impairs feeling in the legs and feet and increases the risk of fractures and falls. Furthermore, diabetes-related vision impairment raises the risk of falls much more.


Early Indications of Diabetes-Related Bone Health Decline


Preventing serious problems requires recognizing the early indicators of bone degeneration.


• Inexplicable Joint discomfort and Stiffness: Chronic joint discomfort, especially in weight-bearing joints like the hips and knees, may be a sign of early osteoarthritis, which is more common in diabetics, or reduced bone integrity.


• Frequent or Minor Fractures: Low-energy trauma, like a small fall or even twisting movements, can cause fractures in diabetics. Particularly frequent fractures occur in the wrist, hip, and spine.


• Delayed Healing: Because diabetes affects the healing response and lowers the nutrient supply to the bone, slower fracture healing or persistent bone pain following small injuries may be signs of reduced bone quality.


Lesser-Known Facts


• Fracture Risk Despite Normal Bone Density: Diabetics, particularly those with type 2 diabetes, may have normal or even higher BMD due to obesity but remain at high risk of fractures due to poor bone quality.
• Type 1 vs. Type 2 Diabetes Impact: Individuals with type 1 diabetes typically experience lower BMD and higher fracture risk early on. Those with type 2 diabetes may have higher BMD but suffer from bone fragility due to metabolic dysfunction.
• Increased Risk of Bone-Related Infections: People with diabetes have a higher risk of osteomyelitis (bone infection) due to reduced immune function, especially after fractures or surgical procedures.



Certain groups of diabetics face a higher risk of bone complications:


Long-standing Diabetics: Individuals who have had diabetes for more than 10 years are at greater risk, especially if blood sugar control has been poor, leading to cumulative damage.
Postmenopausal Women: The combination of estrogen deficiency and diabetes compounds bone loss, making postmenopausal women with diabetes particularly vulnerable to osteoporosis and fractures.


Preventive Measures and Bone Care Strategies


a) Blood Sugar Management: Tight glycemic control is the cornerstone of bone health in diabetics. Research shows that stable glucose levels help minimize the formation of AGEs and reduce inflammation, thereby preserving bone quality.
b) Regular Bone Density Tests: Annual BMD assessments, particularly for those over 50 or with long-standing diabetes, can help detect early signs of bone loss. Dual-energy X-ray absorptiometry (DEXA) is the standard tool for measuring BMD and should be part of a diabetic’s routine screening.
c) Optimize Calcium and Vitamin D Levels: Calcium and vitamin D are essential for bone health. Diabetics may require higher-than-average vitamin D intake, as diabetes can impair the absorption and utilization of these nutrients. Sources include fortified foods, supplements, and moderate sun exposure.
d) Weight-Bearing Exercises: Regular physical activity, including weight-bearing and resistance exercises, can enhance bone density and muscle strength, reducing fall risk. Examples include walking, strength training, and even simple resistance bands exercises.

(By: Dr. Sachin, Consultant – Internal Medicine, SPARSH Hospital, Yelahanka)