Study: Prediabetes as an independent risk factor for broken bones in women

reference

Shieh a, Greenendale G, Cauley J, Karvonen-Gutierrez C, Karlamangla A. Prediabetes and fracture risk in middle age in the study on women's health throughout the country, 1980-2002.Jama network open.2023; 6 (5): E2314835.

Study objective

To investigate whether prediabetes in midlife premenopausal women is associated with postmenopausal bone fractures in women who do not develop overt diabetes.

The second goal of this study was to determine whether, regardless of the bone mineral density, there is a connection between prediabetes and broken bones for women in middle age in menopause (MT).

Key to take away

Prediabetes before MT was associated with a higher fracture rate than in participants who did not have prediabetes.

design

LOngitudinal cohort observation study called Study of Women’s Health Across the Nation (Swan)

Participant

The Swan cohort (Study of Women’s Health Across the Nation) consisted of 3,302 women living in the community between the ages of 42 and 52. They were either in the pre-menopause (no change in menstrual bleeding) or in early perimenopause (less predictable bleeding within a 3-month period).

The analysis group consisted of 1,690 women. The ethnicity of the women was as follows:

• 437 Schwarze Frauen 25,9 %

• 197 chinesische Frauen 11,7 %

• 215 japanische Frauen 12,7 %

• 841 Weiße Frauen 49,8 %

The mean BMI at the start of MT among participants was 27.6 kg/m².

The medium bone mass density (BMD) for the lumbar spine (LS) was 1.059 g/cm²; And for the thigh neck (FN) it was 0.828 g/cm².

Participants of the Swan co-site were excluded if they had no intact uterus and at least one ovarian. They were also excluded if they used hormone therapy or hormone -based contraception.

The Swan cohort came from seven different clinical locations in the United States: Boston, Massachusetts; Chicago, Illinois; Detroit, Michigan; Pittsburgh, Pennsylvania; Los Angeles, California; Newark, New Jersey; and Oakland, California.

The Swan Bone cohort consisted of 2,365 women from five cities: Boston, Massachusetts; Detroit, Michigan; Pittsburgh, Pennsylvania; Los Angeles, California; and Oakland, California.

All participants in the SWAN bone cohort had a baseline visit at baseline and 16 consecutive follow-up visits at an average interval of 1.1 years (interquartile range, QR, 1.0–1.4 years).

The authors defined the beginning of the menopause transition (MT) as "the first visit to the late perimenopause (less predictable menstrual bleeding at least once every 3–12 months)". For women who went into postmenopause directly from premenopause or early perimenopause, the authors defined the beginning of the MT as the first visit after menopause.

In order to be included in the analysis, the participants of the Swan Bone Cohort had to:

• Führen Sie mindestens einen oder mehrere Besuche in der Studie durch

• Machen Sie nach der MT mindestens einen Studienbesuch (zur Überprüfung auf Frakturen).

• Keine knochenfördernden Medikamente einnehmen, einschließlich Hormontherapie, Calcitonin, Calcitriol, Bisphosphonate, Denosumab und Parathormon (33 Frauen wurden aus der Studie ausgeschlossen)

• Es wurde kein Typ-2-Diabetes diagnostiziert (94 Frauen wurden aus der Studie ausgeschlossen)

SWAN Bone Cohort participants were excluded if they:

• Hatte vor MT keine Studienbesuche

• Begann vor MT mit der Einnahme knochenfördernder Medikamente

• Hatten Diabetes Typ 2 (ein Nüchternblutzuckerspiegel von 126 mg/dl vor oder während der MT)

• Wir nahmen eines der folgenden Metformin, Sulfonylharnstoffe, Meglitinid, Thiazolidindion, Dipeptidyl-Peptidase-4-Inhibitoren, Glucagon-ähnliche Peptid-1-Rezeptor-Agonisten oder Insulin ein

• Hatte zwischen dem Beginn der MT und der Fraktur keine Nachuntersuchungen durchgeführt.

The average of the follow -up examination was 12 years.

Evaluated study parameters

At the baseline visit, all fractures were recorded before SWAN. At the seventh visit, the fractures were officially recorded again. Craniofacial and digital fractures were excluded. Traumatic fractures that occurred during a motor vehicle accident, rapid movement, sports, or impact with heavy or fast-moving projectiles were also excluded.

All other traumatic and atraumatic fractures were included in the study.

Prediabetes (glucose levels between 100 and 125 mg/dL) at study visits were tracked:

• Teilnehmer, bei denen nie ein einziger Messwert für Prädiabetes festgestellt wurde, hatten einen Wert von 0

• Teilnehmer, die bei jedem Besuch bis MT Prädiabetes-Werte aufwiesen, hatten einen Wert von 1

• Teilnehmer, die bei mindestens einem Besuch, aber nicht während des gesamten Besuchs an Prädiabetes litten, hatten einen Wert zwischen 0 und 1

Controls for variables have been set up that relate to the risk of fractures in MT age:

• Zigarettenkonsum im Alter MT

• BMI im Alter von MT

• Ethnizität

• Studienort

• Knochenschädigende Medikamente vor dem MT-Alter

• Knochenschädigende Medikamente während der Studie

There was an adjustment of the BMD at MT either in the lumbar spine (LS) or in the femoral neck (FN). These were measured using dual X -ray absorptiometry.

Primary result

Fixed fractures during and after MT and predicative status in front of MT

Most important knowledge

The follow-up period was 12 years from the start.

• 56 Frauen hatten vor der MT Frakturen.

• 136 erlittene Frakturen während der MT oder nach der MT.

• 225 Frauen hatten Prädiabetes und anhaltende Frakturen (11,1 %).

• 111 der Frauen ohne Diabetes erlitten ebenfalls eine Fraktur (7,6 %).

• 33 begannen mit der Einnahme von knochenfördernden Medikamenten und wurden aus der Studie ausgeschlossen.

Participants who had prediabetes at 50% of pre-MT visits had a 49% higher risk of sustaining a fracture after MT or postmenopause than those who did not have prediabetes at any MT.

Participants who had prediabetes at any visit before MT were 120% more likely to suffer a fracture after MT or postmenopause than participants who did not have prediabetes at any MT.

Across all pre-MT visits, a fracture risk of 6.3 per 1,000 person-years was observed in women without prediabetes.

In women with prediabetes, the absolute fracture risk increased by 3 per 1,000 peoplehalfthe pre-MT visits.

For women who had predicates in the meantimeeveryBefore visiting the MT, the climb of the fracture risk was 7 per 1,000 people.

Interestingly, this increase in fracture rates was independent of BMD and overt type 2 diabetes. These results suggest that the increase in fracture risk in prediabetes may not be related to BMD but may represent an entirely separate mechanism.

Of the women in the study, in which at least one visit to the MT, it was found that they had prediabetes were a larger percentage of black, Chinese or Japanese participants.

transparency

Greendale reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Karvonen-Gutierrez reported that she received grants from the NIH during the conduct of the study and grants from the NIH outside of the submitted work. Karlamangla reported receiving grants from NIH during the conduct of the study and personal fees from OptumRx outside of the submitted work. No further disclosures were reported.

Effects and restrictions for practice

The most practical impact of this study relates to the ease of education and testing for our patients.

It is absolutely necessary for women to be informed about their prediabetes or diabetes status when they come to our practice. According to the CDC, a gross estimate between 2017 and 2020 showed that about 38 % of Americans aged 18 or older were based on the sober glucose or HBA1C values ​​tested in the predicative area. Of these 38 %, only 19 % stated that they had been informed by their doctor about the diagnosis.¹

Failure to share the patient's diagnosis with patients is not an acceptable standard of care, especially when correction of prediabetes through lifestyle changes is well documented.

The measurement of sober glucose and HBA1C as well as other standard preventive medical tests in every patient and the transmission of the results can be one of the most insightful aspects of our treatment plans for our patients.

The communication of the diagnosis of prediabetes and the associated health complications that result from untreated prediabetes, such as: B. the development and progression of macrovascular diseases, including cardiovascular diseases, stroke, peripheral vascular disease and now an increased risk of bone breaks in the middle of life, the compliance of patients can improve treatment plans for prediabetes. The support of patients in the changeover of their lifestyle, including nutrition, movement, stress management and weight loss, if indicated, can reverse prediabetes and prevent future disease processes.²

The second clinical implication of this study is to start with our patients between the ages of 30 and 40 discussions about bone health. Real prevention can begin here and be undone, especially if you diagnose prediabetes.

According to a published paperJournal of Women's HealthTalks about a deteriorating bone health usually take place in postmenopausal women about 10 years after the MT when a broken bone has already occurred.³

Talking about bone health only after a fracture is a missed opportunity to discuss prevention measures. Medical conversations in young adult women before menopause can lead to healthier bone health according to MT. The statement that predicted part of the discussion about bone health will be a surprising turn for many patients, which probably has no idea about the connection between prediabetes with fractures after menopause.

Finally, it was found in the study that colored women, especially black, Chinese and Japanese women, suffered more often in prediabetes in the study. The education of these women about current and future consequences in connection with prediabetes and fractures must be paid to special attention.

A new series of research reveals a dangerous racial bias against Black women in the health care system that results in Black women's health concerns not being taken seriously. In some cases the neglect was life-threatening.⁴

To change this narrative and show Black patients that their health is taken seriously by healthcare providers, it is important to ensure simple testing for prediabetes is performed and to share the results and treatment options with our Black patients.

Research shows that racial discrimination, which has a long history in the United States, is now having a negative impact on the health of black women. Understanding that Black women are more likely to develop prediabetes and sharing their results and treatment options during visits begins to correct the racial bias found in this study.⁵

One limitation noted by the study authors is that while it is recognized that the incidence of diabetes and fractures varies by race and ethnicity, there were no tests that could show an association between prediabetes and fractures that varied by race and ethnicity.