Open Access Research article

Fractures are increased and bisphosphonate use decreased in individuals with insulin-dependent diabetes: a 10 year cohort study

Lisa-Ann Fraser14*, Alexandra Papaioannou3, Jonathan D Adachi3, Jinhui Ma2, Lehana Thabane2 and CaMos Research Group

Author Affiliations

1 Department of Medicine, University of Western Ontario, London, Ontario, Canada

2 Department of Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

3 Department of Medicine, McMaster University, Hamilton, Ontario, Canada

4 Division of Endocrinology and Metabolism, St. Joseph’s Hospital, 268 Grosvenor Street, London N6A 4 V2 Ontario, Canada

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BMC Musculoskeletal Disorders 2014, 15:201  doi:10.1186/1471-2474-15-201

Published: 11 June 2014



Individuals with diabetes have been found previously to be at increased risk of non-traumatic fracture. However, it is unclear if these individuals are being identified and treated for osteoporosis.


7753 Canadians over 50 years of age were followed prospectively for 10 years. 606/7753 (7.8%) of had diabetes; 98 were insulin-dependent and 508 were not. Using a cox proportional hazards model, we assessed the association between diabetes status and incident non-traumatic fracture. Using logistic regression we identified factors associated with bisphosphonate use over the 10 year period of study.


Mean (SD) age of participants was 66.7(9.4) years and 72% were female. Those with diabetes had higher BMD T-scores at baseline, with a mean (SD) femoral neck T-Score of -0.97 (1.06), compared to -1.24 (0.99) in the general cohort. The adjusted hazard ratio (HR) for incident non-traumatic fracture in individuals with insulin-dependent diabetes over the 10 year study period was 2.50 (95% confidence interval [CI] 1.60, 3.90; p < 0.001). Despite this increased fracture rate, individuals with diabetes (insulin-dependent or non-insulin-dependent) were less likely to be on bisphosphonate therapy at any point over 10 years of prospective follow up compared to other CaMos subjects (odds ratio [OR]: 0.59; 95% CI 0.46-0.75, p < 0.001).


Despite the increased risk of non-traumatic fracture associated with insulin-dependent diabetes, we that found individuals with diabetes are less likely to be treated with a bisphosphonate than those without diabetes. These findings point to a possible care gap in the treatment of non-traumatic fractures in individuals with diabetes in Canada.

Fracture; Diabetes; Insulin; Care gap; Treatment; Osteoporosis