Longer Duration of Diabetes Strongly Impacts Fracture Risk Assessment: The Manitoba BMD Cohort.
Type 2 diabetes is associated with a higher risk for major osteoporotic fracture (MOF) and hip fracture than predicted by the World Health Organization fracture risk assessment (FRAX) tool.



The objective of the study was to examine the impact of diabetes duration on fracture risk.



Using a clinical dual-energy x-ray absorptiometry registry linked with the Manitoba administrative databases, we identified all women age 40 years or older with 10 or more years of prior health care coverage undergoing hip dual-energy x-ray absorptiometry measurements (1996-2013). Incident MOF and incident hip fractures were each studied over 7 years. Cox proportional hazards models were adjusted for FRAX (FRAX adjusted) and then FRAX plus comorbidity, falls, osteoporosis therapy, or insulin (fully adjusted). FRAX calibration was assessed comparing observed vs predicted probabilities.



There were 49 098 women without and 8840 women with diabetes (31.4% >10 y duration; 20.1% 5-10 y; 23.7% <5 y; 24.8% new onset). In FRAX-adjusted analyses, only duration longer than 10 years was associated with a higher risk for MOF (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.30-1.66), and this was similar in the fully adjusted models (HR 1.34, 95% CI 1.17-1.54). In contrast, a higher risk for hip fracture was seen for all durations in a dose-dependent fashion (eg, FRAX adjusted HR 2.10, 95% CI 1.71-2.59 for duration >10 y vs HR 1.32, 95% CI 1.03-1.69 for new onset). FRAX significantly underestimated the MOF risk (calibration ratio 1.24, 95% CI 1.08-1.39) and hip fracture risk (1.93, 95% CI 1.50-2.35) in those with a diabetes duration longer than 10 years.



Diabetes is a FRAX-independent risk factor for MOF only in women with a long duration of diabetes, but diabetes increases hip fracture risk, regardless of duration. Those with diabetes longer than 10 years are at particularly high risk of fracture, and this elevated risk is currently underestimated by FRAX.
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
Sumit R
SR
Majumdar
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
William D
WD
Leslie
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
Lisa M
LM
Lix
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
Suzanne N
SN
Morin
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
Helena
H
Johansson
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
Anders
A
Oden
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
Eugene V
EV
McCloskey
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
John A
JA
Kanis
D015502:Absorptiometry, Photon; D000328:Adult; D000368:Aged; D015519:Bone Density; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D005260:Female; D005500:Follow-Up Studies; D006620:Hip Fractures / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D008350:Manitoba / Q000453:epidemiology; D008875:Middle Aged; D058866:Osteoporotic Fractures / Q000453:epidemiology / Q000209:etiology*; D012042:Registries; D018570:Risk Assessment; D013997:Time Factors