Mara Schwartz knows firsthand what it’s like living with diabetes and losing bone strength. Thirty-three years ago, during her senior year in high school, Schwartz was diagnosed with type 1 diabetes. Schwartz discovered the connection between diabetes and bone loss on her own as a nurse and later on as a certified diabetes educator (CDE).
After a double mastectomy and hysterectomy, she was diagnosed with osteopenia, a condition that occurs when the body doesn’t make new bone as quickly as it reabsorbs old bone. Making new bone takes longer now for her — something she realized after she broke her toe last year. “I just tapped my toe with a dumbbell during a workout,” says 51-year-old Schwartz. “Instead of a few weeks, the toe took several months to heal and for the pain to go away.”
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For people with diabetes, bone loss can be a major health concern. There’s a sevenfold increase in hip fractures among those with type 1 diabetes and about 1.3-fold increase among those with type 2 diabetes, according to a 2016 report.
“For reasons that are still unclear, people with both type 1 and type 2 diabetes experience a higher incidence of bone fracture than the general population, even though people with type 2 diabetes tend to have above-average bone density,” says endocrinologist Greeshma Shetty, MD, with the Joslin Diabetes Center in Boston. “People with diabetes experiencing bone loss don’t feel the symptoms and don’t know they have weaker bones until they fall and break one.”
Though the bones in the skeleton may seem as solid and unchanging as a stone statue, they are in constant flux. “Our bodies continually break down and absorb old bone and form new bone tissue, but lack of insulin or insulin activity and other factors can interfere with the formation of new bone, and that’s when the risk for fractures increases,” says Derek LeRoith, MD, PhD, professor of medicine in the division of endocrinology, diabetes and bone disease, Icahn School of Medicine at Mt. Sinai in New York City.
Bone loss was never discussed as a risk factor by her doctors, recalls Schwartz. As a CDE, Schwartz makes a point to educate her patients early on about the connection between diabetes and bone health.
Shetty makes time to talk about bone health with her patients, especially those with type 1, who are often diagnosed at an earlier age. There’s some evidence that people with type 1 diabetes achieve lower peak bone mass because of the deficiency of insulin, which helps promote bone growth and strength.
“I make sure to talk to my patients at a relatively young age, even in their 20s if they have type 1 diabetes,” says Shetty. “It’s something that they need to think about for the future because I don’t want them to face a crisis. I want to alert them early on to avoid any fractures.”
There are several bone diseases that people with diabetes are susceptible to, but the most common is osteoporosis. Some 10 million Americans have osteoporosis, and another 44 million have low bone mass, putting them at greater risk of breaking a bone, according to the National Osteoporosis Foundation. It is a chronic condition characterized by reduced bone strength, low bone mass and a higher risk of bone fracture, especially at the hip, spine and wrist.
“There are a number of factors that could contribute to making someone with diabetes more susceptible to bone issues,” says Rachel Stahl, MS, RD, CDE, senior dietitian at NewYork-Presbyterian Hospital. “There are other conditions that may increase risk of bone loss, including genetic abnormalities, chronic kidney disease, developmental disorders and rheumatoid arthritis.”
Currently, there are no recommendations on when people with diabetes should have their bones tested. Doctors make a decision depending on each patient’s risk factors. When a test is needed, experts recommend a bone mineral density, or BMD, test using a central DXA (dual energy X-ray absorptiometry) machine. It is simple, painless, takes 5 to 10 minutes and uses very little radiation.
These tests can measure bone density at the hip and spine and detect osteoporosis before a bone fracture occurs and predict one’s chances of fracturing in the future. If you are age 65 or older and at risk, Medicare Part B covers a bone density test once every 24 months at no cost to you when your doctor orders it. “People with diabetes should talk to their doctors about when they should undergo a bone density test,” says LeRoith.
Smart steps for prevention
There are no magic bullets to avoid bone health problems, but there are several prevention measures that can help, including regular exercise, adopting a balanced diet and making healthy lifestyle choices.
Exercise for life
Bones are living tissue, like muscle, and respond well to exercise by becoming stronger. The best fitness plan for your bones is weight-bearing exercises such as hiking, jogging, stair climbing and even tennis. Strength-training exercises such as lifting weights, using weight machines or lifting your own body weight with push-ups can also strengthen the muscles around the bones and improve balance.
A well-balanced diet should include fruits and vegetables, lean meats, fish, whole grains, legumes, nuts and seeds, and nonfat or low-fat dairy products or other calcium-rich foods each day. Diets should include plenty of calcium and vitamin D, which is important for healthy bones. Good sources of calcium include low-fat dairy products, dark green, leafy vegetables, and calcium-fortified foods and beverages.
Smoking has been found to be bad for bones as well as for the heart and lungs. Women who smoke tend to enter menopause earlier, and that can begin earlier bone loss. In addition, smokers may absorb less calcium from their diets. Alcohol can also negatively affect bone health. Heavy drinkers are more prone to bone loss and fracture because of poor nutrition as well as an increased risk of falling.