The Link Between Diabetes and Bone Disease

If you have diabetes, you probably already know that you have to worry about many potential problems with different body organs–your eyes, your kidneys, your heart. But there is another connection to worry about: your bones. Compared to individuals without diabetes, both men and women with diabetes have a higher risk of fractures, particularly at the hip, with its consequent significant impact on daily life. And if you are older and have diabetes, studies have demonstrated an elevated risk of not only hip fractures, but also those of the upper arm and foot. Women with type 1 diabetes ( the diabetes that results from the loss of insulin production from the pancreas) are approximately 12-fold more likely to have a fracture than women without diabetes, according to data from the Iowa Women’s Health Study. The reasons for why those who have diabetes mellitus have an increased risk for osteoporosis and bone fractures are not entirely clear at this time. This article will discuss some of the potential causes for this associated increased risk and will make some suggestions for prevention of osteoporosis and bone fractures.

JUST WHAT IS THE LINK BETWEEN DIABETES MELLITUS AND OSTEOPOROSIS AND BONE FRACTURES?

There have been several large studies that have shown that individuals with either type 1 diabetes or type 2 ( the diabetes that results from insulin not working as it should, compounded by progressive loss of the body’s ability to make insulin) have increased risk of bone fractures and osteoporosis. The link between fractures and diabetes seems to be stronger if you have type 1 diabetes than if you have type 2 diabetes. Type 1 diabetes is associated with decreased bone mass and although data for bone mass in type 2 diabetes may or may not be decreased, there is evidence of altered bone quality.

The potential causes could be directly from glucose (blood sugar) itself on the quality and strength of the bone. Even the duration of diabetes seems to play a key role given the lower bone density found among those who have had diabetes for over five years. And medications that are used in the treatment of diabetes can also affect the bone. Insulin has been reported to be associated with lower bone density. And results of a trial of 4,360 type 2 diabetic patients treated for a mean of four years with rosiglitazone, metformin or glyburide indicated that rosiglitazone doubled the fracture risk in women, although not in men. Pioglitazone has similarly been reported to increase the fracture risk in women, but not men.

Additionally, if you have diabetes, you have an increased risk of falling. This increased risk could be due to poor circulation and/or diminished sensation in the extremities, decreased vision, or episodes of hypoglycemia (low blood sugar).

VITAMIN D AND CALCIUM: DO THEY PLAY A ROLE IN THE ASSOCIATION OF BONE AND DIABETES?

If you have diabetes, you have an increased risk of having low vitamin D levels. Vitamin D is an important nutrient to help the body absorb calcium, which is needed to maintain bone density. Also, there are some studies that show that vitamin D may help the pancreas release more insulin. Based on some of these initial studies, the National Institutes of Health is sponsoring a large multi-center study to examine whether giving vitamin D can prevent the onset of type 2 diabetes. You can learn more about this study and determine if you want to participate at www.d2dstudy.org.

It has also been reported that individuals that have type 2 diabetes might lose more vitamin D through their urine. And because many with type 2 diabetes are obese and are not physically active, coordination and balance factors that are protective against falling are limited. So even when we think of a larger body size having a higher bone density, those with type 2 diabetes still are at risk of higher fracture rates.

WHAT ARE SOME SIGNS THAT YOU MAY HAVE OSTEOPOROSIS?

Osteoporosis is a silent disease. Often you will not feel anything until you have a fracture. Some important clues that may suggest you have osteoporosis include unexplained height loss, fractures after very little trauma, bone pain (especially in the back), or bone deformities such as a curved spine.

HOW SHOULD YOU BE EVALUATED FOR RISK OF BONE FRACTURES AND OSTEOPOROSIS?

Patients with diabetes should speak to their endocrinologist or primary care doctor about their risks for osteoporosis or bone fractures. Important information to share with your doctor includes any personal past history of fractures or rheumatoid arthritis, loss in height, use of steroids (such as prednisone), a family history of osteoporosis or fractures, and use of tobacco or alcohol products. The risks factors for osteoporosis are listed in the chart here. The American Association of Clinical Endocrinologists (AACE) recommends a bone mineral density test to evaluate bone fracture risk in all women aged 65 and older. However, since diabetes is a potential cause for osteoporosis, AACE also recommends that patients with diabetes may need to have a bone mineral density test earlier in life.

WHAT PROTECTIVE MEASURES CAN BE INSTITUTED?

Healthy lifestyle changes for optimal bone health are important to reduce the risk of osteoporosis and bone fractures. Quitting all tobacco products and limiting, if not completely avoiding, alcohol are important lifestyle changes. Weight-bearing exercises such as walking, jogging and stair climbing can be important to prevent bone loss and can also build muscle strength to prevent falls. Removing hazards in the home and adding non-slip surfaces and handrails in the bathroom are additional measures to reduce the risk of falls. Having good diabetes control and avoiding hypoglycemia will prevent complications associated with falling such as nerve damage, vision loss, circulatory problems and hypoglycemia. Eating a diet that contains 1,000 to 2,000 IU of vitamin D and 1,000 to 1,200 milligrams of calcium can also help prevent bone loss. If your dietary calcium and vitamin D is not enough, supplements can be taken to meet the daily requirement. Finally, speaking to your endocrinologist or primary care physician about your risk of osteoporosis and risk of fractures is important to determine if you need other treatments to improve your bone health.

Selected risk factors for osteoporosis-related fractures


  • Prior low-trauma fracture as an adult
  • Age
  • Low bone mass index
  • Low body weight
  • Family history of osteoporosis
  • Steroid use
  • Cigarette smoking
  • Excessive alcohol use
  • Secondary causes of osteoporosis (e.g., diabetes and rheumatoid arthritis)

Adapted from the 2010 American Association of Clinical Endocrinologists Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis.