Thirty-year-old private school teacher Sini’s (name changed on request) prime concern apart from her professional and personal commitments is the well-being of her 83-year-old diabetic mother. A resident of Kochi in Kerala, Sini’s mother however continues to remain active for her age but has had diabetes for over three decades. Her mother suffered a heart attack about six years ago after the sudden demise of her father.
“In a way, my mother is quite healthy for her age, and she insists on doing all her chores by herself which is a bit scary for me. We always keep telling her to be careful and mindful whenever I step out to go to school. She is on medication for diabetes and was put on pills after her heart attack. Our doctor had also prescribed her calcium supplement tablets. Anyway, thankfully we keep a close watch over her blood sugar levels through periodic checkups and personal care,” Sini says.
She points out that her mother became diabetic post her treatment for an intense bout of asthma but also adds that of late she has been maintaining healthy blood sugar readings. But the family always try to ensure that she doesn’t fall and suffer any bone injury especially due to her age and history of diabetes which puts her in the high-risk category for fracture and frailty-related complications.
Osteoporosis and the risk of suffering bone injuries and fractures could be one of the most worrying concerns of both the elderly and their loved ones, especially if the former has a history of fluctuating blood sugar levels.
“In general, senior citizens are more prone to bone frailty and osteoporosis. This is exaggerated in people with diabetes. The general recommendation is that women above 65 years and all post-menopausal women irrespective of age should get a bone density test done. In men generally, the testing is recommended in those above 70 years,” says Dr V Mohan, chairman and chief diabetologist, Dr Mohan’s Diabetes Specialities Centre, Chennai, in an online interaction with Happiest Health.
Diabetes and osteoporosis
Diabetes and osteoporosis are believed to be closely linked to each other. Osteoporosis could be defined in the simplest terms as the gradual loss of bone strength making the individual’s bone weak and susceptible to a higher risk of fracture and related complications. Those with chronic diabetes could also be suffering from various vascular and neurological impairments which could easily lead them to lose their balance and suffer a fall. This is one of the prime reasons why elderly people with diabetes are often advised to take extra precautions and protect themselves from falling and injuring themselves.
One of the main causes of osteoporosis is attributed to be an anomaly in the bone matrix where osteoblasts, the cells responsible for bone formation lag behind osteoclasts, the bone responsible for bone resorption (osteoclasts are responsible for the death of old bone cells and its assimilation into the bloodstream as new bone cells replace them). In people diagnosed with osteoporosis, the rate of bone formation will be less than that of bone death which results in the overall weakening of the bone.
“Diabetes primarily affects the biomechanical properties of the bone by deteriorating its organic composition and bone material strength. This occurs either directly through altered cross-link formation or indirectly through changes of cellular activity in osteoblasts and bone progenitor cells (cells with the ability to self-renew and form specialised cells),” says Dr DM Mahesh, consultant, endocrinology, Aster CMI Hospital, Bengaluru.
Thus, in people with diabetes, the blood glucose variations and its vascular comorbidities tend to scuttle the functioning of osteoblasts and other bone tissues and cells involved in bone strengthening and mineralisation. The effective functioning of bone-forming cells osteoblasts could get hampered in diabetics due to the fluctuations in the release of cytokines (proteins secreted by cells that play a major role in interactions and communications between cells) and free fatty acids from the hypoxic adipose tissue, which upholds a vicious cycle of chronic inflammation and inhibits osteoblastic activity.
“These changes eventually affect the tensile strength and post-yield properties of the bone, which make the bone tissue in people with diabetes more vulnerable to microdamage accumulation, fragility fractures at most skeletal sites and impaired fracture healing due to vascular deficiencies at the fracture site,” adds Dr Mahesh.
Dr Antonio Brunettti, professor of endocrinology, department of health sciences, University of Magna Graecia and director of the operative unit of endocrinology, AOU Mater Domini, Catanzaro, Italy, in an online interaction with Happiest Health, notes that the overall risk of fragility fractures in people with type 2 diabetes is less pronounced than in people with type 1 diabetes. He also highlights the differences in the nature of fractures in both cases.
“There are differences in the preferential location of fractures with respect to patients with type I diabetes where hip, vertebrae and distal forearm fractures are predominant as against proximal forearm and ankle fractures in those with type 2 diabetes,” says Prof Dr Brunettti. He points out that these differences could be attributed to the diverse body weight and composition of those with type 2 diabetes who are often obese and exert greater pressure and force on the ground and bones while they move around.
Dr Heather Hofflich, professor of medicine, clinical medical director, division of endocrinology and internal medicine, UC San Diego Health, tells Happiest Health in an online interaction that, based on clinical trials, there is a risk of fractures in people with both type 1 and type 2 diabetes. “However, this mechanism is complex and has not been sorted out as of yet. Therefore, it is important to check DEXA scans (to assess bone density) in both males and females with type 1 or 2 diabetes over the age of 50,” she adds.
She also notes that the only ‘extra’ precautions would be to educate anyone with diabetes on fall prevention/osteoporosis prevention mechanisms at an earlier age than the general population. She also elaborates on the osteoporosis support groups at UC San Diego Health and also the national osteoporosis support group in the US called Bone Health and Osteoporosis Foundation (BHOF) which allows people from across the United States to access information and resources on osteoporosis.
The vitamin D factor
Dr Mohan points out that vitamin D deficiency especially in those with diabetes could be one of the main connecting links between poor bone health and diabetes. He also points out that elevated blood glucose leads to chronic inflammation which adversely affects bone mass, mineral density and bone strength.
“People with diabetes are known to have low vitamin D levels. Vitamin D helps to absorb calcium, which is needed to maintain bone density. Elevated blood glucose leads to chronic inflammation which can affect bone mass, mineral density and bone strength. This can occur both in people with type 1 and type 2 diabetes. However, it is more common in people with type 2 diabetes, because type 2 diabetes occurs in older people, whereas type 1 diabetes invariably occurs in younger people,” he says.
Tips for people with diabetes, osteoporosis
- Blood sugar control
- Increasing physical activity and weight-bearing workouts
- Eating nutritious food with increased protein intake
- Maintaining healthy vitamin D and dietary calcium levels
- Restricting the intake of alcohol and avoiding tobacco in any form