Diabetes Increases Risk for Bone Fracture

Folic acid, vitamin B, and insulin mimetics may help keep bones strong

Diabetes Increases Risk for
Bone Fracture

So do high homocysteine levels, which can lead to
osteoporosis—certain B-vitamins can help
By Dr. Edward R. Rosick

oc, I hate getting old." How often have physicians heard that from their patients? Fortunately, you have already taken the first step—self-education—toward combating the liabilities of aging. But aging has its benefits too, such as becoming wiser, seeing our kids grow and prosper, and having the pleasure of being grandparents. What most of us detest is the physical deterioration of age—the impaired hearing and vision, the declining sexual vigor, the loss of mobility, etc.

Among the most common effects of aging is osteoporosis, the progressive loss of bone mass as our bones become thinner and more porous. This condition is thought to afflict at least 10 million older Americans, and 18 million more are thought to have osteopenia, a less advanced form of the same condition. When our bones become porous and fragile, they naturally become more prone to fracture. In the United States alone, it’s estimated that more then 1.5 million fractures are caused by osteoporosis annually, at a cost of 14 billion dollars.

Are You at Risk for Osteoporosis?

Osteoporosis can afflict men and women of all races. If fractures are used as an indicator of osteoporosis, the lifetime risk for men is believed to be between 13 and 25%, and it’s estimated that about 2 million men in the United States have the disease.1 It most often afflicts elderly women, however. At least 40–50% of women over the age of 50 are at high risk (especially if they’re Caucasian or Asian) of suffering an osteoporotic fracture.

Scientists are still not sure how best to prevent, diagnose, or treat osteoporosis (part of the problem is that the disease is asymptomatic until there’s a fracture), but some modifiable risk factors are known, including:

  • A diet low in calcium and vitamin D
  • Inadequate physical exercise
  • Smoking (as if you needed another reason to quit!)
  • Excessive alcohol consumption
  • Estrogen or androgen deficiency
  • Certain types of drugs, such as steroids and hormone suppressants
  • Certain chronic conditions, such as thyroid, liver, or kidney disease and diabetes

Diabetes Is a Risk Factor for Bone Fractures

Although osteoporosis is the chief cause of brittle bones and fractures, diabetes has also been implicated in raising the risk for fractures in middle-aged and elderly people. A Norwegian study looked at the incidence of hip fractures in 35,444 men and women aged 50 or older who had type 1 or type 2 diabetes.2 The researchers found a significantly increased risk of fracture in women younger than 75 with type 1 (juvenile-onset) diabetes or with type 2 (adult-onset) diabetes of long duration. In older men, an increased risk was associated with type 2 diabetes of shorter duration.

Meanwhile, an American study examined the association between type 2 diabetes and hip, leg, and foot fractures in 9654 women aged 65 or older.3 The researchers found that, although diabetes was associated with higher bone mineral density (BMD, a standard measure of the risk for osteoporosis), it was also associated with a higher risk for fractures.

The authors of both papers speculated on why diabetes is associated with fractures. The Norwegian authors postulated that the increased risk was probably not due to loss of bone mass, since in diabetics, BMD tends to be higher than normal. The American authors agreed with this postulate but stated that, even with a higher BMD, diabetics may suffer a decrease in bone strength that isn’t measurable by current methods.

In One Study, the Risk Was 64% Greater

This is what bones look like under an electron microscope.
A new study in the United States has shed further light on the association between type 2 diabetes and the risk for fracture.4 The researchers examined 2979 men and women aged 70–79 (48% male and 42% black) in Pittsburgh and Memphis. Of these individuals, 19% had type 2 diabetes at baseline. Black men had the highest prevalence of diabetes (28%), followed by black women (25%), white men (19%), and white women (9%). For an average period of 4.5 years, the patients were monitored for “nontraumatic fractures” (sounds like an oxymoron, doesn’t it?), defined as fractures occurring spontaneously or due to “modest trauma,” e.g., a fall from a standing height.

The patients with diabetes had a 64% higher risk of fractures than those who did not have diabetes. Compared with those without fractures, diabetic patients who did suffer fractures were more likely to be women than men, and they tended to have a lower total hip BMD and a higher incidence of common diabetic complications. There were no significant differences between the two races.

Cinnamon Contains Compounds that Mimic Insulin

In addition to diet and exercise, both of which are vital for diabetes prevention and treatment, certain natural supplements are known to be safe and effective. Look in almost any kitchen and you’ll find cinnamon, which contains chemical compounds that act as potent insulin mimetics, i.e., they mimic the physiological effects of insulin in controlling blood sugar levels. The compounds having this property are called procyanidins (type A), which are polyphenolic compounds in the larger class called bioflavonoids.5 They’re water-soluble, which is important because it may be undesirable to ingest large amounts of the fat-soluble portion of cinnamon.* (For more supplements that can help with diabetes, see the sidebar.)

*Until recently it was thought that the compound primarily responsible for cinnamon’s antidiabetic effects was MHCP (methylhydroxychalcone polymer), but more detailed research has indicated that the procyanidins provide the primary antidiabetic effects. In any case, the water-soluble cinnamon extracts that contain MHCP also contain the procyanidins.

Other Supplements Can Help Too

Diabetes is a complex disease for which a variety of supplements can be helpful. Prominent among these is lipoic acid, a powerful antioxidant that serves as the linchpin in the body’s antioxidant network; it also functions as a coenzyme in carbohydrate metabolism. Lipoic acid has been shown to be effective in improving the symptoms of nerve damage in diabetic patients.

Chromium has long been used for the treatment of insulin resistance and type 2 diabetes. In a review article on this subject, the authors concluded, “… supplemental chromium has been shown to have beneficial effects without any documented side effects on people with varying degrees of glucose intolerance ranging from mild glucose intolerance to overt type 2 diabetes mellitus.”1

Among the many beneficial components of green tea is the antioxidant bioflavonoid EGCG (epigallocatechin gallate), which has been shown to be able to regulate glucose production in the liver, much as insulin does. Another potent bioflavonoid, quercetin, has been shown in animal studies to be useful in both preventing and treating diabetes.


  1. Anderson RA. Chromium, glucose intolerance, and diabetes. J Am Coll Nutr 1998;17(6):548-55.

A randomized, placebo-controlled study in Pakistan examined the effects of 1, 3, and 6 g of whole cinnamon powder daily in 60 middle-aged men and women with type 2 diabetes.6 After 40 days on this regimen, the patients showed significant decreases (18–29%) in their fasting serum glucose levels, as well as significant reductions in their triglycerides (23–30%), total cholesterol (12–26%), and LDL-cholesterol (7–27%) levels. In all cases, the lowest dose of cinnamon, 1 g/day, was as effective as the two higher doses.

High Homocysteine—A Risk Factor for Fracture

Another risk factor for osteoporosis—high homocysteine levels—has come into focus with two recent studies that examined the association between homocysteine and the risk for osteoporotic fracture in about 4000 middle-aged and elderly male and female patients.7,8 Confirming the conclusions drawn by the authors of the first study, the authors of the second study wrote, “… homocysteine concentration, which is easily modifiable by means of dietary intervention, is an important risk factor for hip fracture in older persons.”

Folic Acid and Vitamin B12 Reduce Risk for Fracture

So what kind of dietary intervention can safely and effectively decrease homocysteine levels? The answer is folic acid (a B-vitamin, also called folate) and vitamin B12. A new study in Japan9 examined the effects of these vitamins on hip fractures in patients who had suffered strokes, because, besides being implicated in osteoporosis, recent studies had linked high homocysteine levels with a higher risk of ischemic stroke (stroke caused by a blood clot in the brain).10,11 Since strokes predispose people to falls, and since high homocysteine levels lead to osteoporosis, which weakens bones, examining whether folate and vitamin B12 can help prevent fractures in patients who have suffered a stroke makes sense.

In a randomized, double-blind, placebo-controlled study of 628 men and women aged 65 or older who had suffered a stroke, the Japanese researchers examined the effects of 5 mg of folic acid and 1500 mcg of vitamin B12 (in the form of methylcobalamin) daily. After 2 years, the researchers found that the supplements had decreased homocysteine levels by 38% and significantly reduced the risk of hip fracture. In their words, “… combined treatment in our population with folate and vitamin B12 is safe and effective in reducing the risk of hip fracture in elderly patients of both sexes following a stroke.”

One must exercise caution in generalizing these findings to a broader, non-Japanese population. It’s known that Caucasians and Asians are at highest risk for osteoporosis, so other populations with a lower risk may not see as much benefit from folic acid and vitamin B12. However, one might still reasonably expect these B-vitamins to have a preventive action in any population, given the established connection between homocysteine and osteoporosis.

With Age Comes Wisdom … Right?

We can’t stop growing older, but I do believe we can optimize the inevitable aging process—not by growing old gracefully, but by growing old wisely. This means eating healthy foods, exercising regularly, and taking scientifically validated supplements that can help fight off the most debilitating conditions of aging, such as diabetes and osteoporosis. Then you can walk off into that sunset with vim and vigor.


  1. Crandall C. Osteoporosis in men. Consultant 2002;42(9):1121-30.
  2. Forsen L, Meyer HE, Midthjell K, Edna TH. Diabetes mellitus and the incidence of hip fracture: results from the Nord-Trondelag Health Survey. Diabetologia 1999;42:920-5.
  3. Schwartz AV, Sellmeyer DE, Ensrud KE, et al., for the Study of Osteoporotic Fractures Research Group. Older women with diabetes have an increased risk of fracture: a prospective study. J Clin Endocrinol Metab 2001;86:32-8.
  4. Strotmeyer ES, Cauley JA, Schwartz AV, et al. Nontraumatic fracture risk with diabetes mellitus and impaired fasting glucose in older white and black adults. Arch Intern Med 2005;165:1612-7.
  5. Anderson RA, Broadhurst CL, Polansky MM, Schmidt WF, Khan A, Flanagan VP, Schoene NW, Graves DJ. Isolation and characterization of polyphenol type-A polymers from cinnamon with insulin-like biological activity. J Agric Food Chem 2004;52:65-70.
  6. Khan A, Safdar M, Khan MMA, Khattak KN, Anderson RA. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care 2003;26(12):3215-8.
  7. van Meurs JB, Dhonukshe-Rutten RA, Pluijm SM, et al. Homocysteine levels and the risk of osteoporotic fracture. NEJM 2004;350:2033-41.
  8. McLean RR, Jacques PF, Selhub J, et al. Homocysteine as a predictive factor for hip fracture in older persons. NEJM 2004;350:2042-9.
  9. Sato Y, Honda Y, Iwamoto J, et al. Effect of folate and mecobalamin on hip fractures in patients with stroke. JAMA 2005;293(9):1082-8.
  10. Boysen G, Brander T, Christensen H, et al. Homocysteine and the risk of recurrent stroke. Stroke 2003;34:1258-61.
  11. Iso H, Moriyama Y, Sato S, et al. Serum total homocysteine concentrations and risk of stroke and its subtypes in Japanese. Circulation 2004;109:2766-72.

Edward R. Rosick, D.O., is an attending physician and clinical asst. prof. of medicine at Pennsylvania State University, where he specializes in preventive and alternative medicine. He also holds a master’s degree in healthcare administration.

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