Prevalence of osteoporosis and vertebral fractures in postmenopausal women with type 2 diabetes mellitus and their relationship with duration of the disease and chronic complications

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Abstract

Controversial data suggest that patients with type 2 diabetes mellitus have an increased risk of fractures despite having, in some studies, higher bone mineral density.

Methods

The aim of this study was to determine the prevalence of osteoporosis and morphometric vertebral fractures in 148 postmenopausal diabetic women, aged 61.87±7.85 years, and their relationship with clinical and metabolic factors and chronic complications of the disease.

Results

The prevalence of osteoporosis was 30.4% at lumbar spine (LS) and 9.5% at femoral neck (FN). The prevalence of vertebral fractures was 23%, mostly mild and located at the thoracic spine. Patients with fractures were older (P<.001), had been in the menopause for a long period (P=.005), had lower creatinine clearance (P=.026) had and lower bone mineral density at LS (P=.01) and FN (P=.042). The frequency of fractures increased with age (P<.001), with the duration of the disease (P=.037) and with the presence of retinopathy (P=.030). In patients with fractures, the prevalence of osteoporosis increased to 40% at LS (P=.004) and to 35.7% at FN (P=.049). After logistic regression adjustment, it was observed that the likelihood of presenting vertebral fractures was significantly increased at the age of 60 years or older (P<.001) and with the presence of osteoporosis at LS (P=.006), irrespective of blood glucose control.

Conclusion

We found a high prevalence of osteoporosis and vertebral fractures in postmenopausal women with type 2 diabetes mellitus, irrespective of blood glucose control, and these conditions were more frequent in long-standing disease and in patients with retinopathy and impaired renal function.

Introduction

Diabetes and osteoporosis are major public health problems that affect a large proportion of older people around the world. The most common problem caused by osteoporosis is vertebral fractures, occurring in about 20% of all postmenopausal women (O'Neill et al., 1996). The proportion of clinically diagnosed vertebral fractures is low; only about 30%–40% of vertebral deformities require medical care, and less than 10% need to be admitted to hospital (Cummings & Melton, 2002). The presence of a vertebral fracture, even when identified as asymptomatic by radiography, is a risk factor for new vertebral and nonvertebral fractures, irrespective of bone mineral density (BMD) (Kanis et al., 2004, The European Prospective Osteoporosis Study (EPOS) Group, 2002a, and is associated with an increase in morbidity and mortality, as well as a decrease in the quality of life (Klotzbuecher, Ross, Landsman, Abbott, & Berger, 2000). The degree of morphometric vertebral deformities is also particularly relevant, since the most severe vertebral fractures cause a great impact on the individual (The European Prospective Osteoporosis Study (EPOS) Group, 2003).

A number of heterogeneous studies have evaluated the association between diabetes, osteoporosis and fractures. A meta-analysis of patients with type 1 and type 2 (DM2) diabetes mellitus confirmed that DM2 patients presented a greater risk of hip fractures and a higher BMD in comparison to control groups (Vestergaard, 2007). Another meta-analysis of 16 eligible studies, of which only 4 investigated vertebral fractures, evaluated the association between diabetes mellitus and fractures and demonstrated that the risk of femoral neck (FN) fractures in female patients with DM2 was 2.1-fold greater and that DM2 is weakly associated with fractures in other regions of the body (Janghorbani, Van Dam, Willett, & Hu, 2007). However, a historical cohort study with residents from Rochester demonstrated that female diabetic patients had a 1.3-fold greater risk of nonvertebral fractures, while the risk for vertebral fractures was 3.1 times greater (Melton, Leibson, Achenbach, Therneau, & Khosla, 2008). Patients with DM2 may have poor bone quality, which cannot be measured by BMD (Yamamoto, Yamaguchi, Yamauchi, Yano, & Sugimoto, 2008), and this may be associated with an increased risk of fractures, especially in postmenopausal women (Yamamoto et al., 2008, Yamamoto et al., 2007). It has thus been suggested that DM2 is a risk factor for fractures (Yamamoto, Yamaguchi, Yamauchi, Kaji, & Sugimoto, 2009), even though its effects on such factors have not been well established (Yamamoto et al., 2009). The aim of this study was to determine the prevalence of osteoporosis and morphometric vertebral fractures and their relationship with clinical and metabolic factors and chronic complications in postmenopausal women with DM2.

Section snippets

Study population and methods

One hundred forty-eight postmenopausal women with DM2 were evaluated. Their mean age was 61.87±7.85 (41–80 years), 57.4% being 60 years or older. Participants were recruited during routine medical evaluations at the endocrine outpatient clinic at Agamenon Magalhães Hospital, Brazilian Health Authority and Teaching System, Recife, Brazil, from March to August 2008. Menopause was defined by amenorrhea for at least 12 months. In patients with past hysterectomy, it was defined by a basal serum

Physical examination

Participants were submitted to a physical examination, including the following: measurement of blood pressure based on criteria from the VII Report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure [National Institutes of Health (NIH), National Heart, Lung, and Blood Institute, 2004]; body mass index (BMI), classified by the US NIH (NIH National Heart, Lung and Blood Institute, 1998); abdominal circumference, defining abdominal obesity in

Biochemical measurements

Blood samples were collected 2 h after lunch to measure postprandial serum glucose (PPG) and fasting to measure serum glucose (FG), triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and creatinine as well as 24-hour urine samples to measure protein excretion. All measurements were conducted by VITROS slides, reactive dry VITROS, with System VITROS 950 Chemistry from the Johnson & Johnson Co (Rochester, NY, USA). Glycosylated hemoglobin A1

Measurement of BMD

BMDs of lumbar spine (LS) and the FN were measured with the dual energy X-ray absorptiometry system LUNAR Prodigy (GE Healthcare, Waukesha, WI, USA). The coefficient of variation of the LS and of the FN measurements was 0.24%. The BMD measurement was expressed by the standard deviation of the mean reference for young adults (T score) and classified using World Health Organization (WHO) parameters (WHO, 1994).

Results

The characteristics of the study patients are shown in Table 1. The prevalence of osteoporosis and osteopenia was 30.4% and 40.5% at LS and 9.5% and 49.3% at FN, respectively. The prevalence of morphometric vertebral fracture was 23%, mostly (83%) mild (grade I), and 65% of them were located at the thoracic spine. The prevalence of osteoporosis increased in these women with vertebral fractures to 40% at LS (P=.004) and 35.7% at FN (P=.049) (Fig. 1). Patients with fractures were significantly

Discussion

Our data showed a high prevalence of osteoporosis among postmenopausal women with DM2, which increased significantly in those with morphometric vertebral fracture. Yamamoto et al. (2007), in a cross-sectional study with 716 controls and 150 Japanese women with DM2 aged between 35 and 89 years (mean age, 63.6 years), of whom 90% of the patients were postmenopausal, identified a morphometric vertebral fractures in 17.3% of DM2 female patients and in 22.1% of the controls, with no statistical

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    Conflict of interest: The authors declare that they have no conflict of interest.

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