Rowan Hillson:Diabetes and fracture risk

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Fractures and Diabetes

Rowan Hillson MBE

National Clinical Director for Diabetes England 2008-18

 

Practical Diabetes Jan/Feb 17

Summary

Fractures are more likely in diabetics compared to non- diabetics. Metabolic factors, an increased risk of falls, complications, infection, medications and the effects of low blood sugars all contribute. Neuropathy is a particular problem. This can cause an abnormal gait, stumbling, and a lack of awareness of actually sustaining injury. Even fractures may not cause anything like the expected pain. Charcot’s foot can cause lifelong disability. Visual problems also cause falls as does the effects of stroke and amputation.

It can help if someone goes round the house to check for trip hazards. Vitamin D supplements and increasing dietary calcium can help. Be aware that sulphonylureas can cause low blood sugars as well as insulin.

If a diabetic, particularly one who has neuropathy, presents with an injury they need careful evaluation to avoid missing fractures.

Fracture risk

Type one women  are six times more likely and type twos are twice as likely to sustain a fracture of the hip than a non diabetic. The longer the diabetes, the more the risk.

Low blood sugars

Low blood sugars are probably under reported by diabetics due to fears about losing their driving licences.

 

charcot-foot

Charcot Foot

Charcot foot presents as a swollen, red foot. There can be an underlying fracture. Because the person does not realise they have a fracture, they continue to weight bear, and this produces deformity of the foot. Best advice is that if a diabetic with neuropathy gets an unexplained inflammation of a foot that they stay off of it and get an urgent assessment by a multi disciplinary team at a diabetic foot clinic. Trouble is, that these are not available for all patients in the UK.

Drugs

Glitazones, eg Pioglitazone, doubles the risk of upper limb fracture in women.  Flozins such as Canaglifozin is suspected of increasing fracture rates and Sulphonyureas definitely do, but probably due to the hypoglycaemic effect.

Falls

Diabetics fall more than their non-diabetic counterparts. 18% of women over the age of 67 with diabetes fell at least once a year. The rate is higher in insulin users, neuropathy,  renal impairment, poor vision and low Hba1cs.

 

 

Low vitamin D doubles total mortality and dementia rates

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Being severely deficient in vitamin D is associated with a doubling of the risk of dementia according to a US study published in Neurology.

The Cardiovascular Health Study ran from the 1990s and tracked 1658 ambulatory citizens with no history of dementia or cardiovascular or cerebrovascular disease.

After a five year follow up time those who had vitamin D levels below 25 nmol/L had increased rates of dementia 2.2 times that of people who had levels over 50 nmol/L.

Researchers say that there are vitamin D receptors in the brain and vitamin D is thought to enhance macrophages that clear amyloid from the brain cells and reduce neuronal cell death.

(Based in article by Michael McCarthy in BMJ 16 August 14).

 

A combined European and US study showed that total mortality was increased by 57% for older adults with vitamin D levels below 25 nmol/L. Cardiovascular deaths and cancer deaths were increased in a dose responsive manner. 

(Based on and article by Stephen Robinson GP News 23 June 14)

Bizarrely the researchers didn’t think of the obvious solution, advise upping sun exposure or taking supplemental vitamin D, but decided that what this meant was that ill people were often stuck indoors and that was why they had low vitamin D levels.

The US study above does seem to contradict that view since all participants were ambulatory and had no known cardiovascular or cerebrovascular disease at the start of the study.  In my own practice in the west of Scotland most patients of all ages had very low levels of vitamin D. All walked into the surgery but had conditions that could have been affected by low vitamin D levels. The only patients who had levels over 50 nmol/L were taking supplements, cycled outdoors all year round, or used sunbeds.