Diabetes and bone healthBoth Type 1 and Type 2 Diabetes affect bone health. Type 1 Diabetes is associated with decreased bone density, whereas for Type 2 Diabetes there is a paradox. They have a higher bone mass density but are also at higher risk of fragility fractures. A fragility fracture is a fracture resulting from a fall from standing height or less. These fractures, which most commonly occur at the hip, spine, or wrist, are an indication that the body's bones have been weakened by an underlying illness. Roughly half of all women and up to one-quarter of all men will suffer a fragility fracture in their lifetime. People who have had a previous fragility fracture are twice as likely to suffer a fracture in the future.This could be due to a bone quality problem - a problem with the structural properties of the bone. There is something called the porosity of the cortex which has been noticed in the people with Diabetes.In addition, some of the medications that people with Diabetes take may adversely affect bone health. Complications of Diabetes such as neuropathy (nerve damage) can actually increase risk of a fall, which could subsequently result in a fracture.Nutrition and bone healthNutrition definitely plays very important role in skeletal health. Osteoporosis especially is a paediatric disease with a geriatric outcome. What we eat as a child could have an effect in bone health in later life. To strengthen your bones, you need to do have a diet which is rich in calcium and vitamin D in childhood which will enable you to attain peak bone mass which then results in stronger bones in later life.For adults, aged 19 to 50 and men aged 51 to 70, the Recommended Dietary Allowance (RDA) is 1,000 milligrams (mg) of calcium a day. The recommendation increases to 1,200 mg a day for women aged 51 and older and for men aged 71 and older.Good sources of calcium include dairy products, almonds, broccoli, kale, canned salmon with bones, sardines and soy products, such as tofu. If you find it difficult to get enough calcium from your diet, ask your doctor about supplements. Obesity and bone healthObese people have bigger loading of bones, this should theoretically decrease risk of fragility fractures. But what happens instead is that obesity increases risk of fractures. Especially when body mass index is over 30, obesity has limited protection against fractures and may even increase the risk of fractures..Menopause, osteoporosis and bone healthWhen women enter menopausal age, they have lower peak bone mass as compared to men. Menopause increases risk of osteoporosis, which in turn increases risk of fragility fracture. During menopause, there is an abrupt cessation of oestrogen, which is the protective female hormone. Men do not undergo this abrupt decrease in the male hormones. As a result, during the first five years of menopause, women can lose a significant amount of bone density, which puts them at a very high risk of fractures in the pre-menopausal state and immediate post-menopausal period.OsteoporosisOsteoporosis by definition means porous bones. It develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. So osteoporosis makes the bone weak and more susceptible to fragility fracture even with very minimal trauma. Osteoporosis is a silent disease - it lacks identifiable symptoms. One indication of osteoporosis is loss of height. Losing more than 4 centimetres of height as compared to your peak adult height, it could definitely suggest your vertebrae could have a fracture.A bone density scan is used to diagnose osteoporosis. This test compares a person's bone density to the bones of an average healthy young adult. The test result, known as a T-score, indicates whether a person has osteoporosis or osteopenia, which is low bone density that is not as severe as osteoporosis. Your doctor may also use other screening tools, including questionnaires, physical exams, and ultrasounds, to predict your risk of having low bone density or breaking a bone..Modifiable (can be changed) risk factors of osteoporosis are:Sex hormonesAbnormal absence of menstrual periods (amenorrhea), low oestrogen level (menopause), and low testosterone level in men can bring on osteoporosis.Anorexia nervosaCharacterised by an irrational fear of weight gain, this eating disorder increases your risk for osteoporosis.Calcium and vitamin D intakeA lifetime diet low in calcium and vitamin D makes you more prone to bone loss.Medication useLong-term use of certain medications, such as glucocorticoids and some anticonvulsants can lead to loss of bone density and fractures.LifestyleAn inactive lifestyle or extended bed rest tends to weaken bones.Cigarette smokingSmoking is bad for bones as well as the heart and lungs.Alcohol intakeExcessive consumption of alcohol increases the risk of bone loss and fractures.Non-modifiable (cannot be changed) risk factors of osteoporosis are:GenderYour chances of developing osteoporosis are greater if you are a woman. Women have less bone tissue and lose bone faster than men because of the changes that happen with menopause.AgeThe older you are, the greater your risk of osteoporosis. Your bones become thinner and weaker as you age.Body sizeSmall, thin-boned women are at greater risk.EthnicityCaucasian and Asian women are at highest risk. African American and Hispanic women have a lower but significant risk.Family historyFracture risk may be due, in part, to heredity. People whose parents have a history of fractures also seem to have reduced bone mass and may be at risk for fractures.Some secondary conditions like hyperthyroidism (overactive thyroid) increases risk of bone loss and fractures. Being on chronic steroids medication used for arthritis and asthma acould also result in bone loss.Preventing osteoporosis80 per cent of osteoporosis is genetic but 20 per cent of osteoporosis can be prevented by:. Eat foods that support bone health - Get enough calcium, vitamin D, and protein each day. Low-fat dairy, leafy green vegetables, fish and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.. Get active - Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.. Do not smoke - Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.. Limit alcohol consumption - Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.However, lifestyle changes may not be enough if you have lost a lot of bone density. There are also several medications to consider. Some can slow your bone loss and others can help rebuild bone.. Medications that slow down bone loss include bisphosphonates, calcitonin, RANKL blockers, estrogen, and drugs that change how estrogen acts in the body.. Medications that help rebuild bone include a synthetic version of the parathyroid hormone and drugs that inhibit a protein called sclerostin.Bone infectionPeople with Diabetes are at high risk for developing infection of the soft tissue and bones of the feet as a consequence of:• various neurologic (nerve damage)• vascular (blood vessel damage)• metabolic (high blood sugar) changesWhen infection sets in the bone it is called as osteomyelitis. Complications of Diabetes include:• Neuropathy (damage of the nerves, especially of the feet)This causes muscles of the feet to lose their ability to contract. This severely diminishes the sensation in the sole of the feet. This deforms the foot and causes high-pressure areas on the sole of the feet. The skin.eventually breaks down and exposes the tissues around the bone. This open wound often gets infected with bacteria leading to collection of pus called an abscess. If left untreated, this infection can spread to the underlying bone causing acute (recent) osteomyelitis.• Vasculopathy (damage to blood vessels causing reduced blood supply to legs)Some patients with long standing Diabetes also have vasculopathy and very high blood glucose levels. This worsens the condition and makes healing of the wound more difficult. When the wound remains unhealed for a long time, the bone is severely infected and this condition is then known as chronic (long standing) osteomyelitis.• Infections transferred from other organsThe bone is infected when germs from an infected tooth or an infection in the lung (pneumonia) travel through the bloodstream and infect the bone. Around 20 per cent of patients who have a diabetic foot ulcer have some form of osteomyelitis in the bone under the wound.Note: A confirmed diagnosis of osteomyelitis in the bone increases the chance of treatment failure and increases the possibility of amputation of the affected area.In people with Diabetes, there are very few signs and symptoms to indicate the presence of chronic bone infection; one indication being a non-healing wound that heals and again breaks down.Confirming a diagnosis of osteomyelitis is essential. To confirm a diagnosis of osteomyelitis the following steps are taken:• The unhealed wound is examined to check if there is any continuous secretion coming from the wound.• Tissue samples are analysed for germ identification and antibiotic sensitivity.• Blood investigation is sought to confirm the presence of infection in the blood and bone.• High resolution digital X-ray helps detect the presence of infection in bone at an early stage.• Magnetic resonance imaging (MRI) helps detect infection in the bones.• A nuclear scan is used when diagnosis is unclear. A safe radioactive substance is given to the patient and images are taken after a certain interval of the whole body or a localised area like the foot. The radioactive substance attaches itself to the infected part of the bone and this helps localise and identify bone infection.• In some cases, a small surgery is performed to retrieve a small piece of bone from the wound. This is sent for analysis and germ identification and sensitivity to determine the best choice of antibiotics. Treatment of osteomyelitisDepending on the stage of the infection and severity, the treatment can range from non-surgical to surgical and often is a combination of the two.Foot careThe wound is cleaned with antiseptic solutions. The foot is protected in a plaster and the patient is advised not to bear weight on the foot. A walker or use of a pair of crutches is recommended until the wound heals and infection is eradicated.Regulated blood sugar levelsHigh sugar levels act as food for the germs and they thrive happily in such an environment as they develop resistance to the antibiotics, which need to be administered for a long duration ranging from six weeks to one year.AntibioticsAfter a positive confirmation of the diagnosis, laboratory test are done, the germ is identified, and its susceptibility to antibiotic is determined. Usually a combination of antibiotics is given, as often there is more than a single type of germs causing bone infection.Hyperbaric oxygen therapyHyperbaric oxygen therapy is sometimes given to help in the healing of the wound.SurgeryIn severe cases, surgery is recommended and the infected bone and surrounding tissue has to be removed from the foot in order to treat the infection..To concludeA healthy active lifestyle, good calcium and vitamin D in your diet may help to prevent bone related problems. Getting an early diagnosis especially if you have risk factors for osteoporosis or osteomyelitis is important. Remember to seek treatment early if you do get fragility fracture as osteoporosis medication may help manage the condition.A comprehensive bone health assessment which includes testing for levels of calcium, phosphorous, vitamin D, alkaline phosphatase, parathyroid hormone (PTH) along with a BMD-DEXA total body scan is essential..Dr Manju Chandran is Senior Consultant Endocrinologist and Director of the Osteoporosis and Bone Metabolism Unit at Singapore General Hospital. Dr. Chandran's clinical and research interests include disorders such as osteoporosis, interaction between diabetes and bone disease, as well as other metabolic bone disorders. Dr. Chandran is the recipient of several international awards.
Diabetes and bone healthBoth Type 1 and Type 2 Diabetes affect bone health. Type 1 Diabetes is associated with decreased bone density, whereas for Type 2 Diabetes there is a paradox. They have a higher bone mass density but are also at higher risk of fragility fractures. A fragility fracture is a fracture resulting from a fall from standing height or less. These fractures, which most commonly occur at the hip, spine, or wrist, are an indication that the body's bones have been weakened by an underlying illness. Roughly half of all women and up to one-quarter of all men will suffer a fragility fracture in their lifetime. People who have had a previous fragility fracture are twice as likely to suffer a fracture in the future.This could be due to a bone quality problem - a problem with the structural properties of the bone. There is something called the porosity of the cortex which has been noticed in the people with Diabetes.In addition, some of the medications that people with Diabetes take may adversely affect bone health. Complications of Diabetes such as neuropathy (nerve damage) can actually increase risk of a fall, which could subsequently result in a fracture.Nutrition and bone healthNutrition definitely plays very important role in skeletal health. Osteoporosis especially is a paediatric disease with a geriatric outcome. What we eat as a child could have an effect in bone health in later life. To strengthen your bones, you need to do have a diet which is rich in calcium and vitamin D in childhood which will enable you to attain peak bone mass which then results in stronger bones in later life.For adults, aged 19 to 50 and men aged 51 to 70, the Recommended Dietary Allowance (RDA) is 1,000 milligrams (mg) of calcium a day. The recommendation increases to 1,200 mg a day for women aged 51 and older and for men aged 71 and older.Good sources of calcium include dairy products, almonds, broccoli, kale, canned salmon with bones, sardines and soy products, such as tofu. If you find it difficult to get enough calcium from your diet, ask your doctor about supplements. Obesity and bone healthObese people have bigger loading of bones, this should theoretically decrease risk of fragility fractures. But what happens instead is that obesity increases risk of fractures. Especially when body mass index is over 30, obesity has limited protection against fractures and may even increase the risk of fractures..Menopause, osteoporosis and bone healthWhen women enter menopausal age, they have lower peak bone mass as compared to men. Menopause increases risk of osteoporosis, which in turn increases risk of fragility fracture. During menopause, there is an abrupt cessation of oestrogen, which is the protective female hormone. Men do not undergo this abrupt decrease in the male hormones. As a result, during the first five years of menopause, women can lose a significant amount of bone density, which puts them at a very high risk of fractures in the pre-menopausal state and immediate post-menopausal period.OsteoporosisOsteoporosis by definition means porous bones. It develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. So osteoporosis makes the bone weak and more susceptible to fragility fracture even with very minimal trauma. Osteoporosis is a silent disease - it lacks identifiable symptoms. One indication of osteoporosis is loss of height. Losing more than 4 centimetres of height as compared to your peak adult height, it could definitely suggest your vertebrae could have a fracture.A bone density scan is used to diagnose osteoporosis. This test compares a person's bone density to the bones of an average healthy young adult. The test result, known as a T-score, indicates whether a person has osteoporosis or osteopenia, which is low bone density that is not as severe as osteoporosis. Your doctor may also use other screening tools, including questionnaires, physical exams, and ultrasounds, to predict your risk of having low bone density or breaking a bone..Modifiable (can be changed) risk factors of osteoporosis are:Sex hormonesAbnormal absence of menstrual periods (amenorrhea), low oestrogen level (menopause), and low testosterone level in men can bring on osteoporosis.Anorexia nervosaCharacterised by an irrational fear of weight gain, this eating disorder increases your risk for osteoporosis.Calcium and vitamin D intakeA lifetime diet low in calcium and vitamin D makes you more prone to bone loss.Medication useLong-term use of certain medications, such as glucocorticoids and some anticonvulsants can lead to loss of bone density and fractures.LifestyleAn inactive lifestyle or extended bed rest tends to weaken bones.Cigarette smokingSmoking is bad for bones as well as the heart and lungs.Alcohol intakeExcessive consumption of alcohol increases the risk of bone loss and fractures.Non-modifiable (cannot be changed) risk factors of osteoporosis are:GenderYour chances of developing osteoporosis are greater if you are a woman. Women have less bone tissue and lose bone faster than men because of the changes that happen with menopause.AgeThe older you are, the greater your risk of osteoporosis. Your bones become thinner and weaker as you age.Body sizeSmall, thin-boned women are at greater risk.EthnicityCaucasian and Asian women are at highest risk. African American and Hispanic women have a lower but significant risk.Family historyFracture risk may be due, in part, to heredity. People whose parents have a history of fractures also seem to have reduced bone mass and may be at risk for fractures.Some secondary conditions like hyperthyroidism (overactive thyroid) increases risk of bone loss and fractures. Being on chronic steroids medication used for arthritis and asthma acould also result in bone loss.Preventing osteoporosis80 per cent of osteoporosis is genetic but 20 per cent of osteoporosis can be prevented by:. Eat foods that support bone health - Get enough calcium, vitamin D, and protein each day. Low-fat dairy, leafy green vegetables, fish and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.. Get active - Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.. Do not smoke - Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.. Limit alcohol consumption - Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.However, lifestyle changes may not be enough if you have lost a lot of bone density. There are also several medications to consider. Some can slow your bone loss and others can help rebuild bone.. Medications that slow down bone loss include bisphosphonates, calcitonin, RANKL blockers, estrogen, and drugs that change how estrogen acts in the body.. Medications that help rebuild bone include a synthetic version of the parathyroid hormone and drugs that inhibit a protein called sclerostin.Bone infectionPeople with Diabetes are at high risk for developing infection of the soft tissue and bones of the feet as a consequence of:• various neurologic (nerve damage)• vascular (blood vessel damage)• metabolic (high blood sugar) changesWhen infection sets in the bone it is called as osteomyelitis. Complications of Diabetes include:• Neuropathy (damage of the nerves, especially of the feet)This causes muscles of the feet to lose their ability to contract. This severely diminishes the sensation in the sole of the feet. This deforms the foot and causes high-pressure areas on the sole of the feet. The skin.eventually breaks down and exposes the tissues around the bone. This open wound often gets infected with bacteria leading to collection of pus called an abscess. If left untreated, this infection can spread to the underlying bone causing acute (recent) osteomyelitis.• Vasculopathy (damage to blood vessels causing reduced blood supply to legs)Some patients with long standing Diabetes also have vasculopathy and very high blood glucose levels. This worsens the condition and makes healing of the wound more difficult. When the wound remains unhealed for a long time, the bone is severely infected and this condition is then known as chronic (long standing) osteomyelitis.• Infections transferred from other organsThe bone is infected when germs from an infected tooth or an infection in the lung (pneumonia) travel through the bloodstream and infect the bone. Around 20 per cent of patients who have a diabetic foot ulcer have some form of osteomyelitis in the bone under the wound.Note: A confirmed diagnosis of osteomyelitis in the bone increases the chance of treatment failure and increases the possibility of amputation of the affected area.In people with Diabetes, there are very few signs and symptoms to indicate the presence of chronic bone infection; one indication being a non-healing wound that heals and again breaks down.Confirming a diagnosis of osteomyelitis is essential. To confirm a diagnosis of osteomyelitis the following steps are taken:• The unhealed wound is examined to check if there is any continuous secretion coming from the wound.• Tissue samples are analysed for germ identification and antibiotic sensitivity.• Blood investigation is sought to confirm the presence of infection in the blood and bone.• High resolution digital X-ray helps detect the presence of infection in bone at an early stage.• Magnetic resonance imaging (MRI) helps detect infection in the bones.• A nuclear scan is used when diagnosis is unclear. A safe radioactive substance is given to the patient and images are taken after a certain interval of the whole body or a localised area like the foot. The radioactive substance attaches itself to the infected part of the bone and this helps localise and identify bone infection.• In some cases, a small surgery is performed to retrieve a small piece of bone from the wound. This is sent for analysis and germ identification and sensitivity to determine the best choice of antibiotics. Treatment of osteomyelitisDepending on the stage of the infection and severity, the treatment can range from non-surgical to surgical and often is a combination of the two.Foot careThe wound is cleaned with antiseptic solutions. The foot is protected in a plaster and the patient is advised not to bear weight on the foot. A walker or use of a pair of crutches is recommended until the wound heals and infection is eradicated.Regulated blood sugar levelsHigh sugar levels act as food for the germs and they thrive happily in such an environment as they develop resistance to the antibiotics, which need to be administered for a long duration ranging from six weeks to one year.AntibioticsAfter a positive confirmation of the diagnosis, laboratory test are done, the germ is identified, and its susceptibility to antibiotic is determined. Usually a combination of antibiotics is given, as often there is more than a single type of germs causing bone infection.Hyperbaric oxygen therapyHyperbaric oxygen therapy is sometimes given to help in the healing of the wound.SurgeryIn severe cases, surgery is recommended and the infected bone and surrounding tissue has to be removed from the foot in order to treat the infection..To concludeA healthy active lifestyle, good calcium and vitamin D in your diet may help to prevent bone related problems. Getting an early diagnosis especially if you have risk factors for osteoporosis or osteomyelitis is important. Remember to seek treatment early if you do get fragility fracture as osteoporosis medication may help manage the condition.A comprehensive bone health assessment which includes testing for levels of calcium, phosphorous, vitamin D, alkaline phosphatase, parathyroid hormone (PTH) along with a BMD-DEXA total body scan is essential..Dr Manju Chandran is Senior Consultant Endocrinologist and Director of the Osteoporosis and Bone Metabolism Unit at Singapore General Hospital. Dr. Chandran's clinical and research interests include disorders such as osteoporosis, interaction between diabetes and bone disease, as well as other metabolic bone disorders. Dr. Chandran is the recipient of several international awards.
