American Journal of Applied Science and Technology
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VOLUME
Vol.05 Issue07 2025
PAGE NO.
52-59
10.37547/ajast/Volume05Issue07-09
Evaluation of Bone Mineral Density among elderly Type
II Diabetes Mellitus Patients in Babil 2025
Abdulmuttaleb Abduljabbar Fayyadh
Department of Family Medicine, Geriatric Medicine, Merjan Teaching Hospital, Babil Health Directorate, Babylon, Iraq.
Received:
07 June 2025;
Accepted:
24 June 2025;
Published:
30 July 2025
Abstract
Background:
Type 2 diabetes mellitus (DM) is associated with various complications, including potential effects on
bone health. Although elderly patients with Type 2 diabetes mellitus may exhibit normal bone mineral density, they
are paradoxically at a higher risk of fractures. The underlying mechanisms remain multifactorial and involve
glycemic control, hormonal regulation, and nutrient deficiencies.
Objective:
To evaluate bone mineral density (BMD) in elderly patients with type 2 diabetes mellitus and investigate
its relationship with glycemic control, vitamin D levels, and calcium status.
Patients and Methods:
A prospective, cross-sectional study was conducted on 46 patients aged > 65 years at Merjan
Teaching Hospital Babil, Iraq, between May 2024 and May 2025. Data collected included demographics, HbA1c
levels, serum vitamin D and calcium levels, and bone mineral density measured via DEXA scans at the spine and
hips.
Results:
Osteoporosis was present in 54.3% of the patients, and 34.8% of the patients were classified as osteopenic.
The majority of the patients were females. A positive correlation was found between HbA1c and DEXA T-scores (r
= 0.313, p = 0.034), and patients with poor glycemic control (mean HbA1c = 9.2%) had a higher prevalence of
osteoporosis. No significant correlations were found between bone mineral density (Dexa T-scores) and serum
vitamin D (r = -0.057, p = 0.705) or calcium levels (r = -0.080, p = 0.597). The right hip had the highest site-specific
prevalence of osteoporosis (41.3%).
Conclusions:
Osteoporosis is highly prevalent among elderly patients, particularly women. Poor glycemic control
(high HbA1c level) and increased age were significantly associated with lower bone density.
Recommendation:
DEXA scans of multiple sites, particularly the spine and hips, are essential for detecting
osteoporosis in this population.
Word count: 2,654 words, excluding references.
Funding Statement: The study was supported by grant NN from the Foundation of Basic Research. This work was
carried out under research program NNN of NN University. Author NN was supported by grant NN from the Ministry
of NN.
Ethical Compliance: All procedures performed in studies involving human participants were in accordance with the
ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration
and its later amendments or comparable ethical standards.
Data Access Statement: Research data supporting this publication are available from the NN repository at located
at www.NNN.org/download/.
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Conflict of Interest declaration: The authors declare that they have no affiliations with or involvement in any
organization or entity with any financial interest in the subject matter or materials discussed in this manuscript.
Author Contributions: AB and MJ contributed to the design and implementation of the research, JK to the analysis
of the results and to the writing of the manuscript. VK conceived the original and supervised the project.
Keywords:
Type 2 diabetes mellitus, Bone mineral density, Osteoporosis, DEXA scan.
1.
Introduction
Bone is a dynamic tissue that undergoes continuous
remodeling involving the coordinated activity of
osteoblasts and osteoclasts. In elderly patients with
T2DM, this balance is disrupted, leading to alterations in
the BMD and an increased risk of fractures.
(1)
Type 2 diabetes mellitus (T2DM) is a prevalent metabolic
disorder that is characterized by insulin resistance and
impaired insulin secretion. In addition to its well-
established
complicationssuch
as
cardiovascular
disease, nephropathy, neuropathy, and retinopathy,
T2DM significantly affects bone health.
(2)
Bone mineral density (BMD) and bone health are critical
yet often overlooked aspects of managing type 2
diabetes mellitus. Although the relationship between
T2DM and bone health is complex, it is clear that
individuals with T2DM are at an increased risk of
fractures due to a combination of factors, such as
altered bone quality, the effects of hyperglycemia,
insulin resistance, medication use, and microvascular
complications.
(3)
Currently, skeletal fragility is considered to be a
complication of T2DM. These patients had an up to 3-
fold increased in hip fracture risk.
(4)
Dual-energy X-ray absorptiometry (DXA) is the primary
tool used to evaluate BMD. DXA is a non-invasive
imaging technique that measures the density of bones
and provides a T-score that compares an individual's
BMD to the average BMD of a healthy young adult of the
same sex. A lower T-score indicates a lower BMD and an
increased risk of fractures.
(5)
Regular screening for BMD and fracture risk is essential
for individuals with T2DM, particularly for those with
additional risk factors. Management strategies that
include
tight
glycemic
control,
appropriate
supplementation of calcium and vitamin D, regular
physical
activity,
weight
management,
and
pharmacological interventions when needed can help
mitigate the adverse effects of T2DM on bone health.
(6)
Continued research into the mechanisms underlying
diabetic bone disease will further aid in developing
effective treatments and preventive measures to
improve bone health in individuals with T2DM. The
integration of advanced imaging technologies and
better management of the underlying metabolic
disturbances can enhance our ability to predict and
address bone health issues in this growing patient
population.
(7)
In individuals with T2DM, the risk of falls may increase
due to diabetic neuropathy, retinopathy, and other
complications, further increasing the risk of fractures.
Thus,
preventing
falls
through
environmental
modifications and strengthening exercises is an integral
part of fracture-prevention strategies.
(8)
Additionally, fall prevention through education and fall
risk assessments should be part of a comprehensive
approach to minimize fracture risk in this population.
(9)
Comprehensive fall prevention programs that include
balance training, gait assessments, and the use of
assistive devices (such as canes or walkers) can
significantly reduce fall-related injuries in diabetic
patients. Moreover, ensuring that home environments
are free of tripping hazards and providing education on
proper footwear can help mitigate the risk of falls.
(10)
2.Patients and Method
2.1 Study Design:
prospective, cross-sectional study
2.2 Study Setting and Duration
The research was conducted at Merjan Teaching
Hospital Babil, Iraq, from May 2024
to
May 2025
.
Eligible
patients visiting the geriatric outpatient clinic were
invited to participate.
2.3 Study Population and Sample Size
A total of 46 elderly patients with T2DM were enrolled
in this study through convenience sampling. The initial
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target sample size was estimated based on the
availability of T2DM patients and the feasibility of
conducting DXA scans within the specified timeframe.
2.3.1 Inclusion Criteria
1.
Elderly patients (≥65 years) with a
confirmed diagnosis of T2DM (based on the
American Diabetes Association [ADA] criteria).
2.
Ability to undergo DXA scanning.
3.
Willingness to complete the study
questionnaire and laboratory tests.
2.3.2 Exclusion Criteria
1.
Other types of diabetes (Type 1
diabetes)
2.
Known metabolic bone diseases (e.g.,
primary hyperparathyroidism, Paget’s disease
of bone) or long-term therapy affecting bone
metabolism (e.g., chronic corticosteroids).
3.
Significant comorbidities could interfere
with the results (e.g., advanced chronic and
malignancy).
4.
Patients unable/unwilling to complete
the study procedures.
2.4 Data Collection
2.4.1 Baseline Assessment and Questionnaire
The researcher prepared a structured, paper-based
questionnaire to collect data. Key information included
the following:
•
Demographics:
Age, and gender
•
Anthropometrics:
Height and weight
(for Body Mass Index [BMI] calculation).
2.4.2 Laboratory Measurements
Blood samples were drawn and processed in the hospital
laboratory according to standardized protocols. The
following parameters were measured.
•
Glycated Hemoglobin (HbA1c)
•
Serum Calcium
•
Serum Vitamin D.
2.4.3 DXA Measurements
BMD
was
assessed
using
dual-energy
X-ray
absorptiometry (DXA) under the guidance of a qualified
radiology technician. Standard positioning protocols
were used to measure the
•
Left Hip
•
Right Hip
•
Lumbar Spine
(vertebrae L1
–
L4)
The results were recorded as T-scores, which compared
the patient’s BMD to that of the healthy reference
population. T-scores were interpreted according to the
World Health Organization (WHO) criteria:
(11)
•
Normal:
T-
score ≤
-1.0
•
Osteopenia:
T-score -1.1-2.5
•
Osteoporosis:
T-
score ≥
-2.5
All scans were reviewed by a radiologist experienced in
DXA interpretation, and regular calibration checks were
performed to maintain equipment accuracy.
2.5. Data Management and Analysis
Data analysis was performed using IBM
®
Statistical
Package for Social Sciences (SPSS) version 27 for
Microsoft
®
Windows 11, and the results are presented as
simple measures of frequency, percentage, mean,
range, and standard deviation and illustrated as tablets.
Statistical significance was set at p- value less than 0.05.
3.Results
The study included 46 elderly patients who underwent
DEXA scan assessment of bone density, with the most
representative age group of the sample being between
71-75 years, including 19 patients (41.3%). The overall
mean age was 73.4 years, range: 65
–
87 years).
Most of the sample was female, accounting for 45
patients (97.8%), while only one male was present 1
(2.2%). As shown in table 3.1.
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Table 3.1.:
Demographic characteristics of the study sample patients (n=46)
Variable
Frequency
Percent
Age (years)
65-70
9
19.6
71-75
19
41.3
>75
18
39.1
Mean ± SD
73.4 ± 8.1
Range
65-87
Gender
Male
1
2.2
Female
45
97.8
HbA1c levels were measured across the patients, with
44 (95.7%) showing levels greater than 6.5%, indicating
poor glycemic control; the mean HbA1c level was 8.6%.
For Vitamin D, 25 patients (54.3%) had levels below 20
ng/mL, 9 patients (19.6%) had levels between 20 and 30
ng/mL, and 12 patients (26.1%) had normal levels
exceeding 30 ng/mL. The mean Vitamin D level was 24.2
with a standard deviation of 13.7; the values ranged
from 8.1 59 ng/mL.
Ionized calcium levels showed that five patients (10.9%)
had low levels < 2.1 mmol/L. The majority (41 patients,
89.1%) had normal levels within the range of 2.1 to 2.9
mmol/L. The mean ionized calcium was 2.27 with a
standard deviation of 0.2, and ranged from 1.87 and
2.86 mmol/L. as shown in table 3.2.
Table 3.2.:
Laboratory measurements among the study sample patients (n=46)
Variable
Frequency
Percent
HbA1c (%)
≤6.5
2
4.3
> 6.5
44
95.7
Mean ± SD
8.6 ± 1.9
Range
6.2-14.4
Vitamin D (ng/mL)
Low (<20)
25
54.3
Sufficient (20-30)
9
19.6
Normal (>30)
12
26.1
Mean ± SD
24.2 ± 13.7
Range
8.1-59
Ionized Calcium (mmol/L)
Low (<2.1)
5
10.9
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Normal 2.1-2.9
41
89.1
Mean ± SD
2.27 ± 0.2
Range
1.87 - 2.86
Patients were sent for DEXA scans across different sites.
In the left hip, 13 patients (28.3%) had normal bone
density (T score ≤
-1.0), 21 patients (45.7%) were
diagnosed with osteopenia (T-score 1.1-2.5), and 12
patients (26.1%) had osteoporosis (T-
score ≥
-2.5).
In the right hip, 12 patients (26.1%) had normal bone
density, 15 (32.6%) had osteopenia, and 19 (41.3%) had
osteoporosis.
Spine measurements revealed that 12 patients (26.1%)
had normal bone density, 19 (41.3%) had osteopenia,
and 15 (32.6%) were diagnosed with osteoporosis.
Overall, the total count across all sites showed that only
five patients (10.9%) had normal bone density, 16
patients (34.8%) had osteopenia, and 25 patients
(54.3%) had osteoporosis. As shown in table 3.3.
Table 3.3.:
DEXA scan results of the patients
Site
measurement
N
%
Left Hip
Normal
13
28.3
Osteopenia
21
45.7
Osteoporosis
12
26.1
Right Hip
Normal
12
26.1
Osteopenia
15
32.6
Osteoporosis
19
41.3
Spine
Normal
12
26.1
Osteopenia
19
41.3
Osteoporosis
15
32.6
Total
Normal
5
10.9
Osteopenia
16
34.8
Osteoporosis
25
54.3
Correlation analysis between DEXA scan results and
other study variables showed that age was positively
and significantly correlated with T-scores, with a
coefficient of 0.411 and a significant p-value of 0.005.
HbA1c also showed a positive and significant
correlation, with a coefficient of 0.313 and p-value of
0.034.
Vitamin D and Calcium levels were inversely correlated
with the DEXA results, with coefficients of -0.057 and -
0.080, respectively, and p-values of 0.705 and 0.597,
respectively; these correlations were not statistically
significant. As shown in table 3.4.
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Table 3.4.:
Correlation analysis between DEXA scan results and other study variables
Predictor
R
P-value
Comment
Age
0.411
0.005
Positive Significant
HbA1c
0.313
0.034
Positive Significant
Vitamin D
-.057-
0.705
Inverse Not Significant
Calcium
-.080-
0.597
Inverse Not Significant
Patients with normal bone density had a mean HbA1c level of 7.8, ranging from 7.3 8.4. Those with osteopenia had
a slightly higher mean HbA1c level of 7.9, ranging from 6.2 12.3. Patients diagnosed with osteoporosis had the
highest mean HbA1c level of 9.2, ranging from 6.6 14.4. as shown in figure 3.1.
Figure 3.1.:
Mean HbA1c results according to DEXA scan T-scores
4.
Discussion
The current study findings revealed a high prevalence of
low bone density, with 54.3% of participants diagnosed
with osteoporosis and an additional 34.8% with
osteopenia. A study by
Sealand et al.
concluded that one
possible connection between diabetes and the bone
involves osteocalcin, a hormone produced by
osteoblasts. However, it is still unclear whether
osteocalcin simply indicates or influences the
relationship between bone and glucose metabolism.
(12)
Yuhao et al.
study in China also found that the combined
prevalence of osteoporosis among patients with type 2
diabetes mellitus (T2DM) was 37.8%. Interestingly, this
condition is more commonly observed in female
patients.
(13)
The demographic profile of the participants was
consistent with established risk factors for osteoporosis.
7.8
7.9
9.2
7
7.5
8
8.5
9
9.5
Normal
Osteopenia
Osteoporosis
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The majority of the patients were female (97.8%) and
elderly, with a mean age of 77.4 years. This aligns with
global and regional epidemiological patterns, where
postmenopausal women constitute the most vulnerable
group to osteoporosis due to estrogen deficiency, which
accelerates bone resorption. Several studies, including
those by
Strotmeyer et al.
and
Parizad et al.
, have
reported similar trends, confirming that aging and
female sex are critical determinants of low BMD in
diabetic populations.
(14,15)
One of the notable findings of the current study is the
positive correlation between HbA1c and BMD (r = 0.313,
p = 0.034). The presence of poor glycemic control,
evidenced by a mean HbA1c of 8.6% and particularly
elevated levels in patients with osteoporosis (mean
9.2%) further supports this link. This is in line with a
study by
Linde et al.
on 1480 diabetic patients who had
undergone a DXA scan and found that after adjusting for
age, BMI, and sex, higher HbA1c levels were also linked
to reduced BMD in the spine and hip. This suggests that
blood glucose levels, as indicated by HbA1c levels, may
serve as a useful predictor of lower BMD in individuals
with diabetes. Their study also found that higher BMI
and female sex were associated with lower bone mineral
density (BMD) in both the spine and hips.
(16)
Another study by
Gao et al.
on 152 postmenopausal
females with T2DM and 326 postmenopausal females
without T2DM found that HbA1c levels above 7.5%
negatively influenced bone mineral density (BMD).
However, they also found no clear association between
HbA1c levels and the risk of developing osteoporosis.
(17)
The current study results showed that vitamin D
deficiency was present in more than half of the
participants (54.3%); however, no statistically significant
correlation was found between vitamin D levels and
BMD (r = -0.057, p = 0.705). Similarly, ionized calcium
levels were not significantly correlated with bone
density (r = -0.080, p = 0.597). Although vitamin D and
calcium are essential for bone metabolism, their isolated
impact on BMD may be overshadowed in diabetic
individuals by dominant metabolic factors, such as
chronic inflammation, oxidative stress, and hormonal
dysregulation. The lack of correlation in our data may
also be due to the small sample size or the confounding
influence of unmeasured variables, such as sun
exposure, physical activity, or supplementation.
Cândido et al.
noted that while vitamin D deficiency is
common in T2DM, it may not independently predict
osteoporosis after adjustment for other variables.
(18)
The DEXA scan results varied according to the
anatomical site. The highest prevalence of osteoporosis
was noted in the right hip (41.3%), followed by the spine
(32.6%) and left hip (26.1%). These variations
underscore the importance of site-specific assessment
as certain areas may be more susceptible to bone loss
based on weight-bearing function, cortical versus
trabecular composition, and patient posture during
imaging. A Study by
Rakic et al.
showed similar findings,
emphasizing the diagnostic value of multisite bone
density measurements in diabetic populations.
(19)
The high prevalence of osteoporosis among elderly
diabetic patients in this study supports the need for
routine BMD screening, this is supported by the results
from a pooled analysis by
Liu et al.
that included 21
studies involving 11,603 patients with type 2 diabetes
mellitus (T2DM) and revealed a high prevalence of
osteoporosis at 27.67% are therefore recommended
routine screening.
(20)
5. Conclusion
Osteoporosis is highly prevalent among elderly patients,
particularly women. Poor glycemic control (high HbA1c
level) and increased age were significantly associated
with lower bone density. Vitamin D deficiency was
common but was not significantly linked to bone density
in this study. DEXA scans of multiple sites, particularly
the spine and hips, are essential for detecting
osteoporosis in this population.
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