If you have diabetes, you’ve likely been told to be vigilant about blood sugar control. That’s because when unmanaged, diabetes can increase your risk of complications such as heart disease, nerve damage, and kidney failure, according to the American Diabetes Association. But there's a lesser-known yet still serious diabetes complication that you’ll also need to watch out for: bone fractures.
“Health care providers often neglect to tell patients with diabetes that they could be at higher risk of bone fractures,” says M. James Lenhard, MD, section chief of endocrinology and medical director of the Diabetes and Metabolic Diseases Center, the Diabetes and Metabolic Research Center, and the Weight Management Center at the Christiana Care Health System in Wilmington, Delaware. However, it's a real risk that can affect people with either type 1 or type 2 diabetes. In fact, people with type 2 diabetes could have three times greater the risk of bone fracture than those with normal blood sugar, depending on skeleton size and how long someone has had diabetes, according to research published in December 2014 in Metabolism.
Type 1 diabetes also increases the risk of bone fractures, according to an animal study. Researchers from the University of Delaware in Newark, where Dr. Lenhard is an adjunct associate professor, and the University of Toronto, found that exercise (normally a good protective step for bone health) did not stimulate bone regeneration as well in mice with high blood sugar levels as it did in mice with normal blood sugar levels. The findings were published online in July 2015 in the journal Bone.
How Diabetes Affects Bone Health
People with type 2 diabetes often have normal or better-than-normal bone density yet their fracture risk is still elevated, notes Lenhard. “This suggests that diabetes affects bone quality … the way that bone is chemically pieced together.”
Bone is living tissue. It’s constantly being broken down and built up again. In people with diabetes, “the cells that come in and lay down new bone protein, which in turn gets calcified to make bone, could perhaps be laying down an abnormal protein or piecing it together abnormally,” Lenhard explains.
When your bones aren’t forming properly, they are more fragile and can break more easily.
How to Prevent Bone Fractures
First and foremost, focus on blood sugar control because "poorly controlled blood sugar is thought to contribute to a deterioration in your bone health,” Lenhard says. When your blood sugar is high, it spills into your urine and makes you urinate more. “There’s always some degree of calcium in your urine," he explains. "The more you have to urinate because of high glucose, the more calcium spills with it."
Exercise is also important — but only if blood glucose is well-controlled, found researchers at the University of Delaware. Weight-bearing exercise — activities in which you’re upright and working against gravity, such as walking, jogging, and strength training — encourage bones to regenerate, says Lenhard. Balance exercises are also important because they can help reduce your chances of falling, a common cause of fracture, according to the American Diabetes Association (ADA).
Before you begin an exercise program, check in with your health care team. Your doctor may want you to avoid certain types of activities that may worsen physical problems you already have, and it’s important to discuss the effect exercise can have on blood sugar if you’re taking glucose-lowering medications.
The next component is your diet. Together, exercise and diet deliver a beneficial one-two punch. “We have had patients improve their bone density with lifestyle changes alone — without medications,” Lenhard says. Start by getting adequate amounts of calcium in your diet. Good sources of calcium include low-fat dairy, dark green leafy vegetables, certain fish, and calcium-fortified foods such as breads and cereals, according to the National Institutes of Health (NIH).
Your body also needs vitamin D to absorb calcium. This is found in limited food sources, including fatty fish, egg yolks, and fortified foods, the NIH reports, and is also produced by the body in response to sun exposure. Just be sure to limit your exposure to UV rays to prevent skin cancer, according to the NIH. Ask your doctor whether you need a supplement to get the right amount of vitamin D for you.
Still, despite your best efforts, you may need medication to prevent osteoporosis, the bone-thinning disease, if your risk for bone fractures is high. According to the ADA, bisphosphonates are among the most common of these drugs; some women may also benefit from temporary estrogen replacement, notes the National Osteoporosis Foundation.
It’s never too late to start the conversation with your health care team about your risk for bone fractures, Lenhard says. Just ask what you should be doing today to protect your bones and avoid this lesser-known yet dangerous complication of diabetes.