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Interaction between frailty, fractures provides insight for 'diabetes bone paradox'

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February 11, 2019

Diabetes was shown to increase frailty, which could compound the effect of the disease on fragility fracture risk, according findings published in Diabetes Care.

Guowei Li

“The concept of frailty and the risk of adverse outcome relies on the fact that the frailer an individual is, the greater the likelihood that the person will experience adverse health outcomes in the future,” Guowei Li, PhD, MBBS, MSc, associate director os the Center for Clinical Epidemiology and Methodology at Guangdong Second Provincial General Hospital in China and assistant professor in the department of Health Research Methods, Evidence, and Impact at McMaster University in Hamilton, Ontario, Canada, and colleagues wrote. “It is, therefore, possible that measuring frailty status may assist in the understanding of the diabetes bone paradox.”

Li and colleagues utilized data on 3,149 participants (mean age, 65.1 years; 69.9% women) from the Canadian Multicentre Osteoporosis Study, which recruited adults aged at least 25 years from nine centers in Canada from 1995 to 1997. Of the total cohort, 138 participants had diabetes (mean age, 69.4 years; 60.1% women) and 3,011 did not (mean age, 64.9 years; 70.3% women). All participants had physical examinations at baseline, 5 years and 10 years to determine height and weight and underwent DXA at the lumbar spine and hip, to determine bone mineral density. A follow-up questionnaire was sent annually to ascertain fracture incidents, hospitalizations and the use of bone health medications. The researchers also measured frailty status by way of an established frailty index, which followed a scale of 0 to 1, with scores closer to 1 indicating increased frailty.

Higher mean frailty index scores were reported in the 138 participants with diabetes compared with the 3,011 participants without (0.22 vs. 0.16; P < .001), equating to a mean frailty index difference of 0.05 (95% CI, 0.03-0.06). In addition, 25.4% of participants with diabetes presented with a fragility fracture compared with 19.1% of the group without diabetes (P < .019).

The researchers found that when fully adjusted, there was a significant relationship between frailty index and fragility fracture risk both for every 0.1 increase in index score (HR = 1.02; 95% CI, 1.01-1.03) and every 0.1 increase in fragility fracture risk (HR = 1.19; 95% CI, 1.1-1.33). Relationships between fragility fracture and diabetes (HR = 1.54; 95% CI, 1.07-2.2) and hip fracture and diabetes (HR = 2.6; 95% CI, 1.04-6.55) were also found.

“This research reveals that measuring frailty status can clarify participants with type 2 diabetes who are truly at high risk of fragility fracture; therefore, particular attention should be paid to diabetes as a risk factor for fractures in those who are frail. Previous studies have reported that diabetes is a significant risk factor for fragility fracture,” Li told Endocrine Today. “However, our results showed not all participants with diabetes had a high risk of fracture (only those with a high degree of frailty were associated with increased fracture risk). Therefore, our study indicated that evaluating frailty status as an effect modifier independent of BMD can improve fracture risk assessment and management in diabetes. – by Phil Neuffer

Disclosures: Li reports he received the Michael G. DeGroote Fellowship Award in Clinical Research from McMaster University, the Post-doctoral Fellowship Award from the Research Institute of St. Joe’s Hamilton, and research grants from the Science Foundation of Guangdong Second Provincial General Hospital. Please see the study for all other authors’ relevant financial disclosures.