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Diabetes Linked to Increased Risk of
Bone Fracture in Older Women
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Older women
with diabetes
have an increased risk of fractures compared with those with nondiabetic women, researchers reported in the January issue
of The Journal of Clinical Endocrinology and Metabolism .
To determine whether type 2 diabetes is linked to fracture in older women, researchers analyzed data from 9,654 women
aged 65 years and older. During an average follow-up period of nine years, 2,624 women said they experienced at least one
nonvertebral fracture. In addition, 388 women reported to have at least one vertebral fracture during the 3.7
years.
Although diabetes was associated with higher bone mineral density, it was also linked to a increased risk of specific
fractures. Older women with diabetes were 80 to 90 percent more likely to have a hip or shoulder fracture.
Compared with nondiabetic women, those with diabetes who were not using insulin had an increased risk of hip or
shoulder fracture. Moreover, those receiving insulin were more than twice as likely to experience foot fractures compared
to nondiabetic women.
In addition, other risk factors that are commonly associated with diabetes and fractures, such as tendency to fall,
poor vision, decreased exercise, poor balance and reduced sensation in the feet, accounted for a small portion of the
association.
"The results from this study clearly demonstrate the need for a more aggressive focus on identifying and addressing
risk factors for fracture in women with diabetes," lead author Dr. Ann Schwartz of the University of California, San
Francisco said. "Now research is needed [to assess] efficacy of current treatments to improve bone strength."
She concluded, "Fracture prevention efforts must be included in the treatment of diabetes."
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| | The
"Non-Compliant" Patient |
Like most
endocrinologists, I often see patients who come to me because they are having difficulty controlling their diabetes under
the supervision of their own doctors. They often turn to a specialist like me for help.
When I review their medical records, I frequently find a note from their doctor that states that the patient is
"non-compliant." Unfortunately, this idea of blaming the patient for a treatment failure is widespread in the medical
community. As I will try to illustrate, this "noncompliant" label is often incorrect.
Take the example of a 46-year-old overweight woman who had an A1c of 12 percent despite taking large doses of insulin.
(Alc provides an estimate of two- to three-month blood sugar control-12 percent indicates extremely poor control.) She was
frustrated more by her failure to improve her blood glucose readings than by her inability to lose weight. When I added one
of the new insulin-sensitizing oral agents to her medication regimen, her A1c fell to 8 percent. She did not lose weight,
but she felt 100 percent better.
Insulin-sensitizing oral drugs can significantly improve glucose control in type 2 patients taking large amounts of
insulin. Physicians need to become aware that it may not be dietary indiscretion (a nice way of saying "cheating") but
insulin resistance that causes the blood sugars to stay elevated. Rather than label these patients "non-compliant,"
physicians need to separate out those who are not making the efforts to change their lifestyles from those whose efforts
have failed due to insulin resistance.
Another example: A mother brought her teenage son to see me for a second opinion. He was waking up most days with high
fasting blood sugars. His doctor accused him of "cheating." The mother told me "my son does not cheat." I recommended that
he check 3 a.m. blood sugars. The 3 a.m. blood sugar ran about 150, but by 7 a.m. it had risen to over 250. The problem was
that his pre-- supper NPH insulin was not lasting through the night. By moving his NPH insulin to bedtime and using three
injections per day, his Alc fell from 10 percent to 7 percent. This was clearly not a case of "non-compliance" but rather
poor control resulting from an inadequate insulin regimen.
A third case involved a 38-year-old man who developed diabetes at age 19. He had never received formal diabetes
education and his diabetes had never been controlled. His physician also labeled him "non-compliant." He is currently
legally blind and on dialysis.
Would his life be different today had he received diabetes education and intensive insulin therapy? No one can say for
sure. We do know that diabetic microvascular complications (those of the small blood vessels) are primarily the result of
high blood sugars (hyperglycemia). However, other factors such as genetics may have contributed to the development of his
complications.
Since the Diabetes Control and Complications Trial (DCCT) results were published in 1993, intensive insulin therapy
(with three to four daily injections or the insulin pump) to achieve "tight" glucose control has become the standard of
care. Some physicians, however, still limit patients to two injections per day.
The more recently published United Kingdom Prospective Diabetes Study (UKPDS) has convincingly demonstrated that most
patients with type 2 diabetes progressively lose beta cell function (the ability to make insulin) within five to ten years
after the diagnosis is made. Therefore these patients will eventually need two or more oral agents and/or insulin to
maintain good control. If their physicians do not recognize this fact, they may incorrectly attribute the deteriorating
control of their patients to "non-compliance." What can you, as the patient, do to convince your doctor that you take your
diabetes seriously and are working hard to control it? I recommend that you bring detailed blood sugar records and a diary
that lists your food intake, exercises, and daily stresses to each office visit. (For example, your diary may reveal that
you are eating more to prevent hypoglycemia).
If your blood sugars are too high despite your hard work, tell your physician that you are, in fact, adhering to his
or her treatment plan. Challenge your physician to reconsider your treatment plan and explore other options to intensify
your therapy. Seek out a certified diabetes educator who is a nurse or dietitian to help you to better understand how
insulin and oral agents work. They may offer suggestions to your physician.
The bottom line: Empower yourself by becoming an active participant in your own diabetes management. |
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