Diabetes and Musculoskeletal Health

Diabetes, a chronic metabolic disorder, encompasses two main types: type 1 diabetes (T1D) and type 2 diabetes (T2D). Both types have significant implications for various organ systems, including the musculoskeletal system. Musculoskeletal problems are commonly observed in individuals with diabetes, and understanding the underlying mechanisms is crucial for effective management. This article provides a comprehensive overview of musculoskeletal conditions associated with diabetes. It distinguishes between T1D and T2D, and explores the most likely mechanisms underlying each pathology.

Osteoporosis

Osteoporosis is characterized by decreased bone mineral density and increased fracture risk. It is more prevalent in individuals with diabetes. T1D is associated with decreased bone formation, impaired osteoblast activity, and alterations in the receptor activator of nuclear factor kappa-B ligand (RANKL)/osteoprotegerin (OPG) system. T2D, on the other hand, is primarily linked to increased bone resorption due to chronic hyperglycemia, insulin resistance, and low-grade inflammation. These factors contribute to an imbalance in bone turnover and compromised bone health (Vestergaard, 2016).

Osteoarthritis

Osteoarthritis is a degenerative joint disease. It is influenced by both T1D and T2D. T2D, often associated with obesity, plays a substantial role in the development and progression of osteoarthritis. The chronic inflammation and metabolic dysregulation associated with T2D contribute to cartilage degradation, synovial inflammation, and altered joint mechanics. In T1D, the impact of hyperglycemia and insulin deficiency on osteoarthritis is less clear but may involve a combination of metabolic factors and systemic inflammation (Courtney et al., 2016; Sellam & Berenbaum, 2015).

Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is characterized by shoulder joint stiffness and restricted movement. It is more prevalent in individuals with T1D and T2D. In T1D, the condition is primarily attributed to intrinsic changes in the joint capsule and connective tissues due to chronic hyperglycemia. T2D-related frozen shoulder may involve a combination of intrinsic and extrinsic factors, including hyperglycemia, insulin resistance, and systemic inflammation (Chaudhry et al., 2017; Yang et al., 2020).

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist, and is associated with both T1D and T2D. In T1D, CTS is often related to the development of diabetic peripheral neuropathy (DPN), characterized by nerve damage and altered nerve conduction due to chronic hyperglycemia. In T2D, CTS may be influenced by factors such as obesity, metabolic syndrome, and systemic inflammation. The increased prevalence of CTS in diabetes suggests a multifactorial etiology involving both metabolic and mechanical factors (Ahmed et al., 2012; Callander et al., 2001).

Peripheral Neuropathy

Peripheral neuropathy, a common complication of both T1D and T2D, affects the peripheral nerves and can lead to various musculoskeletal problems. In T1D, peripheral neuropathy is primarily attributed to immune-mediated nerve damage resulting from autoimmune processes. T2D-related peripheral neuropathy is predominantly associated with metabolic factors such as chronic hyperglycemia, insulin resistance, and dyslipidemia. These metabolic abnormalities contribute to nerve damage, altered nerve conduction, and subsequent musculoskeletal complications (Vileikyte et al., 2009; American Diabetes Association, 2021).

Conclusion

Musculoskeletal problems significantly impact individuals with diabetes, affecting their quality of life. Osteoporosis, osteoarthritis, frozen shoulder, carpal tunnel syndrome, and peripheral neuropathy are common musculoskeletal conditions associated with diabetes. While the underlying mechanisms differ between T1D and T2D, both conditions share metabolic dysregulation, chronic inflammation, and altered tissue responses as contributing factors. Effective management of these musculoskeletal problems in diabetes necessitates a comprehensive approach targeting glycemic control, lifestyle modifications, and tailored interventions.

References:

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2. American Diabetes Association. Standards of Medical Care in Diabetes—2021. Diabetes Care. 2021;44(suppl 1):S1-S232. doi: 10.2337/dc21-S001
3. Callander CL, Beard CM, Kurland LT, et al. Carpal tunnel syndrome in a general population. Neurology. 2001;56(3):289-292. doi: 10.1212/wnl.56.3.289
4. Chaudhry H, Farrar JT, Nagaraja HN, et al. Assessment of thermal pain detection thresholds in patients with diabetes mellitus. J Foot Ankle Res. 2017;10:28. doi:10.1186/s13047-017-0206-1
5. Courtney CA, Steffen AD, Fernandes L, et al. Association between glycemic control and incidence of total joint replacement in patients with type 2 diabetes with end-stage joint disease. Diabetes Care. 2016;39(11):e182-e183. doi: 10.2337/dc16-1394
6. Sellam J, Berenbaum F. Is osteoarthritis a metabolic disease? Joint Bone Spine. 2015;82(2):73-77. doi: 10.1016/j.jbspin.2014.09.006
7. Vestergaard P. Diabetes and bone. J Diabetes Complications. 2016;30(7):1265-1269. doi: 10.1016/j.jdiacomp.2016.06.012
8. Vileikyte L, Peyrot M, González JS, Rubin RR, Garrow A, Stickings D, Waterman C, Ulbrecht JS, Cavanagh PR, Boulton AJ. Predictors of depressive symptoms in persons with diabetic peripheral neuropathy: a longitudinal study. Diabetologia. 2009;52(7):1265-1273. doi: 10.1007/s00125-009-1363-3
9. Wang Y, Bao X, Yang Y, et al. Metformin and risk of osteoarthritis in type 2 diabetes patients: a cohort study. Int J Endocrinol. 2015;2015:678050. doi:10.1155/2015/678050
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Vegans At Greater Risk of Fracture?

About a month ago a worrying study was published by researchers working on the EPIC-Oxford Study. They looked into the differences in fracture risk between meat eaters, vegetarians and vegans. It was done by following a group of around 55,000 men and women for an average of 17 years. It should be said that most fractures are generally due to poor bone health leading to decreased bone mineral density (BMD) and eventually osteoporosis.

The authors note that previous studies have shown that vegetarians (and vegans) have lower BMD than non-vegetarians but that the associated fracture risk is unclear. The combination of vitamin D and calcium has been found to be effective in decreasing fracture risk. Studies have also linked protein intake to bone health. High protein intake increases intestinal calcium absorption and stimulates the production of insulin-like growth factor (IGF-1) which is associated with better bone health. And finally, body mass index (BMI) could also play a part in fracture risk. The lower BMD found in US vegetarians may be explained by their lower BMI.

Tong et al. summarise their findings as follows:

 “The higher observed risks of fractures in non-meat eaters were usually stronger before BMI adjustment, which suggests that the risk differences were likely partially due to differences in BMI. Vegetarians and vegans generally have lower BMI than meat eaters, and previous studies have reported an inverse association between BMI and some fractures, particularly hip fractures, possibly due to reasons including the cushioning against impact force during a fall, enhanced oestrogen production with increased adiposity, or stronger bones from increased weight-bearing.”

“Although a statistically significant higher risk of total and hip fractures was only observed in vegans in the lower BMI category (<?22.5?kg/m²), our interpretation is limited by the small numbers of cases in each stratum in these analyses, especially because of the strong correlation between diet group and BMI, which results in very few vegans in the higher BMI category, and vice versa comparatively small numbers of meat eaters with a low BMI.”

“In this study and previous studies, vegans had substantially lower intakes of calcium than other diet groups since they do not consume dairy, a major source of dietary calcium, while both vegetarians and vegans had lower protein intakes on average. In the human body, 99% of calcium is present in bones and teeth in the form of hydroxyapatite, which in cases of calcium deficiency gets resorbed to maintain the metabolic calcium balance, and thus, osteoporosis could occur if the calcium was not restored.”

“Overall, vegans in this study had higher risks of total and some site-specific fractures (hip, leg, vertebra) than meat eaters. The strongest associations were observed for hip fractures, for which fish eaters, vegetarians, and vegans all had higher risks. These risk differences might be partially explained by the lower average BMI, and lower average intakes of calcium and protein in the non-meat eaters. However, because the differences remained, especially in vegans, after accounting for these factors, other unaccounted for factors may be important.”

We have known for some time that astronauts suffer from bone loss whilst in space. This is partly due to the effect of weightlessness and reduced physical activity leading to decreased bone compressive forces. Bone compressive forces help increase BMD and create stronger bones. As vegans usually have lower BMIs, their bones are subject to smaller compressive forces than meat-eaters. This can be overcome by resistance exercise and weight lifting. And of course, it is particularly important for those eating a plant-based diet to ensure they get an adequate intake of vitamin D, calcium and protein to maintain bone health.

Soft Drinks May Cause Menopausal Hip Fractures

A study published this month in the journal Menopause looked into the relationships between carbonated soft drink consumption, osteoporosis (hip and lumbar spine) and incidental hip fractures. For almost 12 years Kremer et al. followed over 72,000 postmenopausal women from the Women’s Health Initiative Observational Study.

The results showed no associations between soft drink consumption and hip or lumbar spine bone mineral density – this finding was in contradiction with previous studies that had found an association. Consuming at least 14 carbonated soft drinks per week was associated with incident hip fractures. The relationship was statistically significant for caffeine-free soft drinks but not for caffeinated soft drinks. Interestingly, there was no significant risk if the intake was less than 14 servings per week, suggesting a ‘threshold effect’ rather than a ‘linear dose-response’ relationship. Drinking more than 14 carbonated soft drinks (non-caffeinated) per week led to a 32% increase in risk of hip fracture compared to women that didn’t drink any soft drinks.

The authors postulate that added sugars may have “a negative impact on mineral homeostasis and calcium balance“. Also, the carbonation of soft drinks “results in the formation of carbonic acid that might alter gastric acidity and, consequently, nutrient absorption“.