title: Functional Impairments Mediate Association Between Clinical Fracture Risk and Type 2 Diabetes Mellitus in Older Women.
abstract: OBJECTIVE
  To examine the effect of functional impairments in older women with diabetes mellitus (DM) on incident clinical fractures.
  
  
  METHODS
  Secondary analysis of two large prospective cohort studies.
  
  
  METHODS
  North Carolina Established Populations for Epidemiologic Studies of the Elderly (EPESE) and Women's Health Initiative (WHI) clinical trials.
  
  
  METHODS
  EPESE included 2,704 community-dwelling women aged 65 and older; WHI clinical trials included 68,125 postmenopausal women.
  
  
  METHODS
  Women with DM at baseline were compared with women without in successive Cox proportional hazards models. Functional limitations were determined according to self-reported difficulties with activities of daily living (ADLs) and physical activities.
  
  
  RESULTS
  The risk of any clinical fracture during the study period was greater in women with DM, after controlling for age, race and ethnicity, and body mass index, in the EPESE (hazard ratio (HR) = 1.36, 95% confidence interval (CI) = 1.08-1.72) and WHI (HR = 1.29, 95% CI = 1.19-1.39) cohorts. After inclusion of functional limitations, the greater risk of fracture associated with DM decreased in the EPESE (HR = 1.25, 95% CI = 0.98-1.59) and WHI (HR = 1.21, 95% CI = 1.12-1.31) cohorts. In participants with DM, difficulties with moderate physical activities, such as bending or stooping, walking several blocks, and heavy housework, were significantly associated with incident fracture (P < .05).
  
  
  CONCLUSIONS
  Older women with DM are at greater risk of clinical fractures than those without, independent of bone mineral density. Greater functional impairment in moderate physical activities mediates this greater fracture risk in part, although there remains an unexplained residual DM-associated risk for fracture.
authors.affiliation: Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University Medical Center, School of Medicine, Durham, North Carolina.|Center for the Study of Aging and Human Development, School of Medicine, Durham, North Carolina.|Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Lee
authors.affiliation: Center for the Study of Aging and Human Development, School of Medicine, Durham, North Carolina.|Department of Biostatistics and Bioinformatics, Duke University Medical Center, School of Medicine, Durham, North Carolina.
authors.forename: Carl F
authors.initials: CF
authors.lastname: Pieper
authors.affiliation: Center for the Study of Aging and Human Development, School of Medicine, Durham, North Carolina.|Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.|Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Cathleen
authors.initials: C
authors.lastname: Colón-Emeric
mesh_terms: D000058:Accidental Falls / Q000706:statistics & numerical data*; D000203:Activities of Daily Living; D000368:Aged; D015992:Body Mass Index; D015519:Bone Density; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D050723:Fractures, Bone / Q000453:epidemiology / Q000209:etiology* / Q000503:physiopathology; D015577:Geriatric Assessment / Q000379:methods*; D006305:Health Status Indicators; D006801:Humans; D015994:Incidence; D009043:Motor Activity / Q000502:physiology*; D009657:North Carolina / Q000453:epidemiology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors
keywords: diabetes mellitus; fracture; functional impairments