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The diabetes-fracture association in women with type 1 and type 2 diabetes is partially mediated by falls: a 15-year longitudinal study

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Abstract

Summary

This study evaluated mediators of fracture risk in postmenopausal women with type 1 (T1D) and type 2 diabetes (T2D), over a 15-year follow-up period. This study provides evidence that the increased fracture risk in women with T1D or T2D is partially explained by falls. Furthermore, a shorter reproductive lifespan in women with T1D contributes modestly to fracture risk in this cohort.

Purpose

Skeletal fragility is associated with diabetes mellitus, while limited estrogen exposure during the reproductive years also predisposes to lower bone mass and higher fracture risk. We aimed to determine osteoporosis diagnosis, fall and fracture rates in women with type 1 (T1D) and type 2 (T2D) diabetes mellitus, and explore mediators of the diabetes-fracture relationship.

Methods

Prospective observational data drawn from the Australian Longitudinal Study in Women’s Health (ALSWH) from 1996 to 2010. Women were randomly selected from the national health insurance database. Standardized data collection occurred at six survey time points, with main outcome measures being self-reported osteoporosis, incident fracture, falls, and reproductive lifespan. Mediation analyses were performed to elucidate relevant intermediaries in the diabetes-fracture relationship.

Results

Exactly 11,313 women were included at baseline (T1D, n = 107; T2D, n = 333; controls, n = 10,873). A total of 885 new cases of osteoporosis and 1099 incident fractures were reported over 15 years. Women with T1D or T2D reported more falls and fall-related injuries; additionally, women with T1D had a shorter reproductive lifespan. While fracture risk was increased in women with diabetes (T1D: OR 2.28, 95% CI 1.53–3.40; T2D: OR 2.40, 95% CI 1.90–3.03), compared with controls, adjustment for falls attenuated the risk of fracture by 10% and 6% in T1D and T2D, respectively. In women with T1D, reproductive lifespan modestly attenuated fracture risk by 4%.

Conclusion

Women with T1D and T2D have an increased risk of fracture, which may be partially explained by increased falls, and to a lesser extent by shorter reproductive lifespan, in T1D.

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Data availability

Information to access the datasets can be found at www.alswh.org.au

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Acknowledgments

The research on which this paper is based was conducted as part of the Australian Longitudinal Study on Women’s Health, by the University of Queensland, and the University of Newcastle. and to the women who provided the survey data.

Funding

The authors received financial support from the Australian Government Department of Health.

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Authors and Affiliations

  1. Departments of Endocrinology & Diabetes, Monash Health, Clayton, Victoria, Australia

    E. P. Thong, A. E. Joham, P. R. Ebeling & H. J. Teede

  2. Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia

    E. P. Thong, F. Milat, J. C. Enticott, A. E. Joham & H. J. Teede

  3. Hudson Institute of Medical Research, Clayton, Victoria, Australia

    F. Milat

  4. Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia

    P. R. Ebeling

  5. Centre for Longitudinal and Life Course Research, School of Public Health, University of Queensland, St Lucia, Queensland, Australia

    G. D. Mishra

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  1. E. P. Thong
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Correspondence to H. J. Teede.

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Thong, E.P., Milat, F., Enticott, J.C. et al. The diabetes-fracture association in women with type 1 and type 2 diabetes is partially mediated by falls: a 15-year longitudinal study. Osteoporos Int 32, 1175–1184 (2021). https://doi.org/10.1007/s00198-020-05771-9

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