Are Your Prediabetic Patients at Increased Risk of Bone Fracture?

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Type 2 diabetes increases the risk of bone fracture significantly. For example, one report found that women diagnosed with diabetes after age 40 had a 30 percent increased risk of having any non-vertebral fracture and an 82 percent increased risk of hip fracture compared to women without diabetes. In addition, research shows that increased falls, fall-related injuries, and fall-related fractures are also more prevalent in diabetics, even after controlling for poor balance.

But do prediabetics also have an increased risk of bone fracture? In a recent cohort study that was published in JAMA Network Open featuring 1,690 middle-aged women with prediabetes, there was a clear association between prediabetes and increased fracture risk as a woman ages.

“This new research is significant because it highlights the overlapping risks between prediabetes, blood sugar issues, and fracture risk,” explained diabetes expert Beverly Yates, ND, creator of the Yates Protocol for prediabetes and diabetes. “This research also reminds clinicians that they should not wait until a diabetes diagnosis to address bone health in their prediabetic patients.”

Mechanisms of Action 

There are several connections between blood sugar and bone health. Research indicates that the accumulation of advanced glycation end-products (AGEs) plays a key role in the progression of many diabetes complications, including fracture risk. AGEs negatively impact collagen fibers which reduces bone strength independent of bone mineral density. This is particularly true with uncontrolled diabetes, as elevated glucose levels accelerate AGE formation, potentially leading to fragile bones. Diabetes is also associated with decreased bone turnover and impaired bone homeostasis. Research indicates that patients with prediabetes also have lower bone turnover and worse trabecular bone microarchitecture.

“It's true that not every person with prediabetes will develop type 2 diabetes or have diabetic complications,” explained Yates, “however, this new research highlights fracture risk as an independent factor in patients with prediabetes regardless of a possible future type 2 diabetes diagnosis.”

Other Contributing Factors

In her clinical practice, Yates addresses bone health by focusing on nutrient absorption. “If a person’s gut is compromised, they are not digesting, absorbing, and assimilating the nutrients they need to not only control blood sugar but also protect bone health,” she said.

Physical activity is also a key factor. “Exercise not only improves blood sugar control, but it also improves both bone density and bone strength,” she explained. Lack of exercise is also associated with the development of prediabetes.

“There are five lifestyle factors that I focus on with my prediabetic and diabetic patients, and they are nutrition, sleep, stress management, meal timing, and exercise, including both resistance and weight training," she said. After she assesses and restores the patient's gut health so they can digest and absorb nutrient-dense foods, she helps her patients understand the role that key lifestyle activities can play for both blood sugar control and bone health.

“I explain to my patients that poor sleep and a lack of recovery from stress will likely leave them compromised and struggling with their blood sugar levels and digestion and will also put them at increased risk of developing a bone fracture,” she said. 

Clinical Significance

From 2017 to 2020, the Centers for Disease Control and Prevention (CDC) estimated that 38 percent of all American adults had prediabetes, with that percentage jumping to nearly 49 percent in adults aged 65 or older. In 2019 alone, the CDC estimated that 96 million adults had prediabetes. 

This is a significant number of people who may also be at increased risk of bone fracture. Addressing this issue in clinical practice with an integrative approach that includes diet and lifestyle will help ease the burden of bone fracture, which can be debilitating and even deadly.