While it is acknowledged that people with type 1 diabetes (T1D) and type 2 diabetes (T2D) are at increased risk of cardiovascular and microvascular disease, diabetes-induced skeletal fragility is an important but generally ignored complication. People with T2D have two- to threefold higher risk of hip fracture than people without diabetes, while in patients with T1D the risk is increased sixfold (1). While bone density is reflective of fracture risk in T1D, this relationship is not as consistent in T2D. Clinical practice guidelines for osteoporosis management generally recommend that individuals aged ≥50 years with risk factors be screened with bone mineral density (BMD) testing and those at high risk for fractures be treated with antiosteoporosis medication and calcium and vitamin D supplementation (2–4). Although T1D and, more recently, T2D are considered risk factors for fractures and falls, it is unknown what proportion of patients receives osteoporosis screening and management as part of their routine diabetes care (5).
We evaluated osteoporosis screening and management practices of endocrinologists caring for adults with diabetes at the McGill University Health Centre, a large academic institution in Montreal, Canada. Identification of medical records was done in two steps to ensure a broad sampling of the patient population. We first identified all men and women ≥50 years old with T1D or T2D who had at least three visits to the Division of Endocrinology clinics between January 2015 and December 2018 and retrieved their electronic files through the local data warehouse. From these records, we randomly selected 1 in 15 files for detailed review. The data warehouse provides visit and hospitalization details, patient demographics, and results of institution-based biochemistry and imaging investigations. From the randomly selected medical records, we extracted information on clinical risk factors for osteoporosis, antiosteoporosis medication use, and lifestyle recommendations documented in clinic notes and results of biochemistry and imaging (BMD and spine radiography) investigations. Descriptive statistics were used to describe the analytical cohorts; categorical variables were expressed as frequencies and percentages, and continuous variables were expressed as means and SD. Logistic regression was performed to assess the association between baseline characteristics and BMD measurement in the sample from the data warehouse.
We identified 3,262 individuals meeting inclusion criteria from the data warehouse; the mean age was 66 years (SD 10), 55% were female, and 4% had a prior fracture documented by hospitalization or emergency department visits in the medical records. BMD measurement was performed in 14% of the study population; calcium, phosphorus, and magnesium were measured in 25–36%, 25-hydroxyvitamin D was measured in 16%, and alkaline phosphatase and renal function were quantified in 43–49%. In regression analysis, those who had a prior fracture (versus none) and women (versus men) were more likely to have had BMD screening (odds ratio 2.5, 95% CI 1.4–4.4, and odds ratio 1.9, 95% CI 1.5–2.3, respectively).
We identified charts of 214 individuals for detailed review; 11% had T1D, and 89% had T2D. The mean HbA1c was 7.8% (SD 1.5). Endocrinologists reported a fracture after age 40 years in 4%, a history of glucocorticoid use in 9%, and a history of hormone therapy in 3%. We noted that 15% of individuals (7% of men and 26% of women) had undergone BMD screening; 4% of these had BMD T scores ≤−2.5, and thoracolumbar spine radiographs were present for 6% (3% of men and 9% of women). The records noted that 52% of patients (52.1% of men, 63.5% of women) received vitamin D supplementation and 7% (5% of men, 12% of women) received either bisphosphonates or denosumab. In patients ≥ 65 years old (n = 118), only 16% had undergone BMD screening. In patients who had an important clinical risk factor for fracture (glucocorticoid use, prior fracture, or BMD T score <−2.5; n = 41), 22% received antiosteoporosis medication.
Limitations of the study include the cross-sectional design, the reliance on chart review, and selection bias associated with practices at one academic center. Nonetheless, we believe our results reflect the current osteoporosis care gap in standard care in diabetes management. Although adults with diabetes have increased skeletal fragility, our results support that current identification and management of those at risk for fracture is suboptimal. In particular, we observed a worse pattern of investigation in men than women. Overall, this indicates the need for increased awareness and possible integration of bone health into diabetes guidelines and T1D and T2D as risk factors in fracture risk assessment tools.
Funding. Funding for this work came from a clinical research grant from the Division of Endocrinology and Metabolism, McGill University, Montreal, Canada.
The funding source had no role in the design of the study, analysis of the results, writing of the manuscript, or decision to submit for publication.
Duality of Interest. No potential conflicts of interest relevant to this article were reported.
Author Contributions. All authors discussed and agreed on study design and execution. M.-R.P. and M.B.-S.-A. performed selected chart review. C.B. performed the statistical analysis. M.-R.P., M.B.-S.-A., C.B., and S.N.M. interpreted the data and wrote the manuscript. All authors reviewed and accepted the final manuscript. S.N.M. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.