Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Region Västra Götaland, Närhälsan Norrmalm Health Centre, Skövde, Sweden.
PLoS Med. 2023 Jan 26;20(1):e1004172. doi: 10.1371/journal.pmed.1004172. eCollection 2023 Jan.
BACKGROUND: Type 2 diabetes mellitus (T2DM) is considered a risk factor for fracture but the evidence regarding the impact of T2DM on fracture risk is conflicting. The objective of the study was to determine if patients with T2DM have increased fracture risk and if T2DM-related risk factors could be identified. METHODS AND FINDINGS: In this national cohort study in Sweden, we investigated the risk of fracture in 580,127 T2DM patients, identified through the national diabetes register including from both primary care and hospitals, and an equal number of population-based controls without diabetes matched for age, sex, and county from 2007 to 2017. The mean age at entry was 66.7 years and 43.6% were women. During a median follow-up time of 6.6 (interquartile range (IQR) 3.1 to 9.8) years, patients with T2DM had a marginally but significantly increased risk of major osteoporotic fracture (MOF) (hazard ratio (HR) 1.01 (95% confidence interval [CI] 1.00 to 1.03)) and hip fracture (HR 1.06 (95% CI 1.04 to 1.08)) compared to controls, associations that were only minimally affected (HR 1.05 (95% CI 1.03 to 1.06) and HR 1.11 (95% CI 1.09 to 1.14), respectively) by multivariable adjustment (age, sex, marital status, and an additional 20 variables related to general morbidity, cardiovascular status, risk of falls, and fracture). In a multivariable-adjusted Cox model, the proportion of the risk for all fracture outcomes (Heller's R2) explained by T2DM was below 0.1%. Among the T2DM patients, important risk factors for fracture were a low BMI (<25 kg/m2), long diabetes duration (≥15 years), insulin treatment, and low physical activity. In total, 55% of the T2DM patients had none of these risk factors and a significantly lower fracture risk than their respective controls. The relatively short mean duration of T2DM and lack of bone density data, constitute limitations of the analysis. CONCLUSION: In this study, we observed only a marginally increased fracture risk in T2DM, a condition that explained less than 0.1% of the fracture risk. Consideration of the herein identified T2DM-related risk factors could be used to stratify T2DM patients according to fracture risk.
背景：2 型糖尿病（T2DM）被认为是骨折的危险因素，但关于 T2DM 对骨折风险的影响的证据存在矛盾。本研究的目的是确定 T2DM 患者是否有更高的骨折风险，以及是否可以确定与 T2DM 相关的风险因素。
方法和发现：在这项瑞典的全国性队列研究中，我们调查了 580127 例 T2DM 患者的骨折风险，这些患者是通过国家糖尿病登记处（包括初级保健和医院）确定的，同期还匹配了 580127 名年龄、性别和居住地相匹配的无糖尿病的人群作为对照。入组时的平均年龄为 66.7 岁，43.6%为女性。在中位随访时间为 6.6 年（四分位距 3.1 至 9.8）期间，与对照组相比，T2DM 患者发生主要骨质疏松性骨折（MOF）（风险比 [HR] 1.01（95%置信区间 [CI] 1.00 至 1.03））和髋部骨折（HR 1.06（95% CI 1.04 至 1.08））的风险略有但显著增加，这些关联在多变量调整（年龄、性别、婚姻状况和另外 20 个与一般发病情况、心血管状况、跌倒风险和骨折相关的变量）后仅有轻微影响（HR 1.05（95% CI 1.03 至 1.06）和 HR 1.11（95% CI 1.09 至 1.14））。在多变量调整的 Cox 模型中，T2DM 解释的所有骨折结局（Heller 的 R2）的风险比例低于 0.1%。在 T2DM 患者中，骨折的重要危险因素包括低 BMI（<25 kg/m2）、较长的糖尿病病程（≥15 年）、胰岛素治疗和低体力活动。总的来说，55%的 T2DM 患者没有这些危险因素，骨折风险明显低于各自的对照组。T2DM 的平均病程相对较短，且缺乏骨密度数据，这构成了分析的局限性。
结论：在这项研究中，我们观察到 T2DM 患者的骨折风险仅略有增加，T2DM 仅解释了不到 0.1%的骨折风险。考虑到这里确定的与 T2DM 相关的风险因素，可以根据骨折风险对 T2DM 患者进行分层。
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