Wobbly, Weak Bones

Introduction

Obesity and diabetes are becoming more prevalent across all age groups in the United

States, and these diseases could affect an adolescent’s health both short and long-term into

adulthood. This group is more susceptible to developing poor body image, risky eating

behaviors, insulin resistance just to name a few. Adolescence is a crucial time in their life

because this is the point where they gain stature and start to develop a strong skeletal frame

that will support them throughout life. Calcium is one of the minerals that play a role in the

ossification and resorption of the skeletal frame. This remodeling process involves bone cells

secreting enzymes to break down the calcium while simultaneously replacing calcium to build

stronger bones. When osteoclasts break down bone faster than it is being rebuilt, the bones can

become fragile, and porous. This imbalance puts a person at risk for osteoporosis, which can

lead to a loss of height, a weak skeleton, and bone fractures. Foods and soft drinks that are

empty-calorie, high in fat and sugar, and low in nutrients, are some of the key factors that

correlate with being obese and developing type 2 diabetes. These foods and beverages are

sweet, rich in flavor, and leave little room for nutrients like calcium that are essential for

adequate bone growth in adolescents. As the rates of metabolic diseases like obesity and

diabetes increase across all ages, science is starting to investigate how these diseases can

affect bone health.

Current research

Factors like genetics, environment, a sedentary lifestyle, and economic issues contribute

to obesity being a multi-faceted problem. The treatment plan for obesity is to prevent future

weight gain, lose weight, and maintain a healthy weight. Since obesity is becoming such a

problem in the United States, research is being conducted looking specifically at how obesity

can affect bone health. Bones need a stimulus such as mechanical stress in order to build more

bone. When a bone is put under stress or force, this causes the bone to become weaker with
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microtears. Osteoblasts are turned on, migrate to the affected area, and secrete a matrix to help

repair the bone. Body weight and other forces like weight-bearing exercise can help bones

become stronger. People who are overweight or obese should have stronger bones due to the

extra amount of stress being put on the bones. A study was conducted on Finnish women for

three generations and it found that an increase in body weight and fat decreases the strength of

their bones, but this is not the case for children.1 The possible explanation could be due to a

term called skeletal unloading. If an individual is sedentary or immobile, the bones will be under

minimal stress, and more fat cells will proliferate while osteoblastogenesis will decrease.1 The

individual will be not repairing or making new bone, so their bones could possibly become

weaker. A prospective cross-sectional study used convenience sampling of 2213 children aged

two to seventeen and categorized their BMIs.2 They came to the conclusion that obese children

were not at risk for fractures in their extremities.2 The study hints that a possible explanation

could be due to the relationship between bone mineral density and the odds of a fracture.2 It

could be possible that overweight and obese children have higher bone mineral densities which

put them at less risk for fractures. Researchers cannot seem to agree who is at risk for fractures

and who is not. Discrepancies in research such as the study group, factors such as male verse

female, and overweight verse obese are creating controversial results.

The kind of fat and the location of the fat in the body could be another indication of your

bone health. Visceral fat is more harmful than subcutaneous because it covers vital organs and

could possibly disrupt their natural processes like hormones. One common issue we see with

obesity is a disruption of hormones. Hormones need ideal conditions in order to carry out their

functions properly. When the specific pathway is interrupted, hormone cycles can become

erratic and many processes can be distorted. Obese individuals have higher levels of estrogen

which is produced by white adipose tissue and this may increase bone loss in obese post-

menopausal women.1 CT and MRI scans can measure visceral and subcutaneous fat. Visceral

fat was found to be correlated with reduced bone mass while subcutaneous fat was found to be
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more beneficial to protecting bones.1 So possibly visceral fat is messing up the synchronism of

hormones but subcutaneous is helping to put more stress on the bones. After menopause

estrogen levels decrease for women. Women who are post-menopausal and obese have been

found to have lower osteocalcin levels which are responsible for bone formation.1 Therefore, an

increase in visceral fat can potentially increase the estrogen that is circulating around in the

body. Hormones are complex and sensitive so any changes in the pathway could lead to

unwanted and unknown effects on many systems and organs.

The mesenchymal cell is responsible for creating and directing adipocytes and

osteoblasts.4 This is a complex process that involves pathways with specific receptors and

enzymes. Cytokines are cells that are responsible for communicating signals to other cells

regarding things like inflammation, repair, infection, etc. They are like the policeman who is

directing traffic and communicating with drivers on where to drive. When infection takes place in

a cell, these cytokines communicate to other cells and eventually, macrophages come and

engulf the bacteria. In obese people, cytokines are elevated, and this leads to an increase in

inflammation. The hypothesis is that cytokines create instability in the mesenchymal cell and

somehow modify the receptor which turns on osteoclasts leading to bone resoprtion.4

Cytokines can be triggered by parathyroid hormone (PTH). PTH is responsible for increasing

the absorption of calcium. If calcium in the blood is too low, PTH will stimulate bone resorption,

stimulate calcium absorption in the kidneys and activate vitamin D. This allows for the intestine

to get ready to absorb calcium. This process is also affected by fat mass and is also responsible

for releasing cytokines.1 The processes that happen in the body are intricate and intertwined so

a change in the system can directly affect the body in many ways.

Type one diabetes sometimes known as juvenile diabetes is when the pancreas either

makes little or no insulin. Insulin is the hormone that is released by the pancreas when blood

sugar is high, and insulin helps facilitate sugar or glucose into the cell. When there is little, or no

insulin produced by the pancreas this results in hyperglycemia. Since this disease is most likely
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noticed during adolescence, blood sugar levels can remain unchecked until a symptom occurs.

In type one, insulin growth like factor one and hyperglycemia may disrupt bone growth during

adolescence and lead to a lower bone mass later in adulthood.4 As we age, our bones stop

absorbing minerals and we start to lose bone mass usually in our forties. If bones do not

achieve an adequate amount of reserves during adolescence, this will put them at risk for

osteoporosis and bone fractures as they age. Another interesting point to consider is that

hyperglycemia can affect vitamin D and calcium absorption.4 These two nutrients are important

when it comes to bone ossification. Adolescents have become a prime target for food

advertising, especially fast food. Most of the time, the food is low in calcium and vitamin D and

adolescents prefer sugar and caffeinated drinks. Many adolescents are not consuming enough

of these vital nutrients appropriate for peak bone growth. Now add impaired absorption of

vitamin D and calcium and you have the perfect recipe for low bone mineral density. If

adolescents have problems with eating disorders or malabsorption this may not be easily

detected.4 If these symptoms are not well defined it can be hard to diagnose someone and help

treat the condition early on. This can lead to a lack of nutrition, low bone mineral density, and a

low body weight. If this happens in adolescence, this will directly affect bone quality, bone

density, and could possibly lead to osteoporosis and other bone-related diseases.

Most of the time people with diabetes also suffer from other complications like kidney

disease, damage to blood vessels, which could potentially put them at a higher risk for fractures.

The kidneys cannot function correctly and excrete more calcium than usual into the urine

diminishing bone mineral density. In order to test this hypothesis, a case study was conducted

to see if diabetes and the complications of diabetes put a person at risk for fractures. After

adjusting for the complications of diabetes, they found that there is little difference in overall

fractures for type one and type two diabetes.5 The only difference was that type one is more

susceptible to hip fractures due to diabetic kidney disease.5 This led to the conclusion that high

blood sugar levels could be the culprit for an increase in fractures compared to the
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complications of other diseases from diabetes. Type one diabetes may require a different

treatment plan when it comes to bone health compared to type two diabetes.

Type two diabetes is when your pancreas secretes insulin, but cells become resistant

resulting in hyperglycemia and hyperinsulinemia. In type two, insulin growth like factor is

elevated and this increases bone formation. Obese people with type two have a higher BMD

possibly due to the elevated levels of insulin, estrogen, and mechanical loading.4 Yet they are

still at risk for fractures. Science is hypothesizing that the bone quality is somehow

compromised so the skeletal frame does not have the adequate amount of minerals making it

weak.4 A high-resolution computed tomography examined post-menopausal women with type 2

and measured the hard (cortical) and spongey (trabecular) components of their nondominant

forearm and leg.6 They found that fractures could be due to resistance to bending due to the

shift of less intracortical bone compared to the increase in the trabecular part of the bone.6 The

cortical part of the bone is important because it’s the outer hard surface that helps the bone in

weight-bearing and during bending. If the cortical portion of the bone is weak and cannot

support force or stress than it could fracture more easily. If this theory is correct, people with

type two diabetes are at risk for bone diseases like osteoporosis which can be detrimental to

their bone health and potentially put them at risk for fractures.

Conclusion

Diabetes and obesity are increasing dramatically and can be very detrimental to

adolescents. These diseases are becoming more prevalent due to high caloric, high fat and

sugar, food, soft drinks and a sedentary lifestyle. Obesity and type two diabetes are diseases

that can be prevented through healthy eating habits, and an active lifestyle. Despite the

inconclusiveness of research, physicians need to be aware of the possibility of diabetes and

obesity affecting bone health especially when it comes to adolescents. If adolescents miss the

window for peak bone mass this could put them at a disadvantage as their age into adulthood.

Many people are going under the knife and getting Bariatric surgery to help them achieve a
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healthy weight. But certain procedures can disrupt calcium and vitamin D absorption and can

lead to the weakening of bones putting someone with diabetes even more at risk for bone

complications. Research in this field and its effects on bones is complex and inconclusive.

Researchers are finding contradicting results and future research is crucial in an attempt to find

a possible correlation. Diabetes and obesity are complex issues in which many systems and

processes are intertwined. These diseases already cost the United States millions of dollars and

if we dismiss the new research, we only are adding to the cost of healthcare spending.
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Work Cited

1. Shapses SA, Claudia Pop L, Wang Y. Obesity is a concern for bone health with aging.

Nutrition Research. 2016;39:1-13. (review) DOI:10.1016/j.nutres.2016.12.010 PMID:

28385284

2. Sabhaney V, et la. Bone fractures in children: Is there an association with obesity? The

Journal of Pediatrics. 2014;165:313-318. (primary) DOI: 10.1016/j.jpeds.2014.04.006

PMID: 24836073

3. Cao JJ. Effects of obesity on bone metabolism. Journal of Orthopedic Surgery and

Research. 2011;6(30):1-7. (review) DOI: 10.1186/1749-799X-6-30 PMID: 21676245

4. Al-Hariri M. Sweet Bones: The Pathogenesis of Bone Alteration in Diabetes. Journal of

Diabetes Research. 2016;1-5. (review) DOI: 10.1155/2016/6969040 PMID: 27777961

5. Vestergaard P. Rejnmark L. Mosekilde L. Diabetes and its complications and their

relationship with risk of fractures in type 1 and 2 diabetes. Calci ed Tissue International

2008;84(1)45–55. (primary) DOI: 10.1007/s00223-008-9195-5 PMID: 19067021

6. Burghardt AJ, Issever AS, Schwartz AV. High-resolution peripheral quantitative computed

tomographic imaging of cortical and trabecular bone microarchitecture in patients with type

2 diabetes mellitus. Endocrine Research. 2010;95(11):5045-5055. (primary) DOI:

10.1210/jc.2010-0226 PMID: 20719835