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Objectives: To study the relationship between body composition, bone mineral density and some characteristics in patients with type 2 diabetes mellitus. Subjects and methods: A crosssectional analysis study was carried out on 151 patients with type 2 diabetes, aged 36 - 81, and examined glucose, HbA1c, insulin, and C-peptide by using the Cobas 6000 and Cobas e 601 automated systems from Roche at the Nghean General Friendship Hospital.
Journal of military pharmaco-medicine no7-2018 CHARACTERISTICS OF BONE MINERAL DENSITY, BODY COMPOSITION IN PATIENTS WITH TYPE DIABETES Ngo Duc Ky*; Doan Van De**; Dang Hong Hoa** SUMMARY Objectives: To study the relationship between body composition, bone mineral density and some characteristics in patients with type diabetes mellitus Subjects and methods: A crosssectional analysis study was carried out on 151 patients with type diabetes, aged 36 - 81, and examined glucose, HbA1c, insulin, and C-peptide by using the Cobas 6000 and Cobas e 601 automated systems from Roche at the Nghean General Friendship Hospital Measurement of total body bone density by American Hologram Discovery QDR series 4500A/SL The HOMA2IR was calculated according to the HOMA Calculator v2.2.3 software version of Oxford University (UK) Results: The avarage age of subjects was 62.12 ± 8.99 years Average BMI was 22.96 ± 2.98 kg/m² There were no differences in age, BMI, HbA1c and HOMA2 between men and women Bone mineral density in females (0.942 ± 0.103 g/cm²) was lower than males (1.087 ± 0.097 g/cm²) The body fat distribution, as well as total body fat of women were statistically significantly higher than men (p < 0.01) In contrast, lean and total body weight of men were significantly higher than women (p < 0.05) Both % fat trunk and total body % fat in the HbA1c < 7% were significantly lower than those with HbA1c ≥ 7% The bone mineral density of group HbA1c < 7% was (1.0542 ± 0.1258 g/cm²) higher than that of group HbA1c ≥ 7% (0.9937 ± 0.1177 g/cm²) (p < 0.01) Conclusions: Fat percentage is related to HbA1c levels more than fat mass In patients with better glycemic control, bone mineral density is increased * Keywords: Type diabetes; Bone mineral density; Body composition INTRODUCTION Recently, many studies in the world have addressed the relationship between body composition, bone mineral density (BMD) and diabetes Osteoporosis is also a metabolic disorder Type diabetes has a risk factor of bone loss and fracture in humans and animal experiments [1, 4] On the other hand, bone is also studied as an endocrine organ that is involved in some hormones metabolism and is associated with insulin resistance in diabetic patients [2] Studies on BMD, body mass composition in patients with type diabetes have shown different results Studies show that there is a change in the tendency to increase or no change in BMD in patients with type diabetes [7, 8] The opposite results for BMD in patients with type diabetes may be explained by differences in race, different country or study design Weight control is a very important goal in the treatment of type diabetes Therefore, we conducted this study in order to: * Nghean General Frienship Hospital ** 103 Military Hospital Corresponding author: Ngo Duc Ky (ngoduckyna@gmail.com) Date received: 25/06/2018 Date accepted: 22/08/2018 124 Journal of military pharmaco-medicine no7-2018 - Survey BMD and body mass composition in patients with type diabetes - Study the relationship between BMD and body composition with HbA1c in patients with type diabetes SUBJECTS AND METHODS Subjects A total of 151 patients, aged 36 - 81, diagnosed with type diabetes and treated at Nghean General Friendship Hospital from 07 - 2015 to 02 - 2017 Methods A cross-sectional study was carried out on 151 patients with type diabetes All patients examined glucose, HbA1c, insulin, and C-peptide by using the Cobas 6000 and Cobas e 601 automated systems from Roche at the Nghean General Friendship Hospital Measurement of total body bone density by American Hologram Discovery QDR series 4500A/SL Calculates the HOMA2-IR and HOMA2-% beta ratios according to the HOMA Calculator v2.2.3 software version of Oxford University (UK) Measured BMD at lumbar spine L1-L4 and femoral neck of all subjects by dual energy X-ray absorption (DEXA) Measured body composition and fat content by hydrodensitometry, bioelectric impedance, and dual energy X-ray absorptiometry (DXA) DXA provides a reliable estimate the total body composition Some body composition indexes are obtained by DXA, such as fat mass (FM), lean mass (LM), BMD, fat percentage (BF) HbA1c, insulin, glucose, C-peptide tested performed on Roche Cobas 6000 * Data analysis: Data were managed by using Epi.info 6.04 and all statistical analyses were carried out by using SPSS 16.0 RESULTS AND DISCUSSION General characteristics of the research group Table 1: Features Male (n = 76) Female (n = 75) Both (n = 151) p-values 61.71 ± 9.59 62.53 ± 8.38 62.12 ± 8.99 > 0.05 76 (50.3%) 75 (49.7%) BMI (kg/m²) 23.06 ± 2.90 22.86 ± 3.07 22.96 ± 2.98 > 0.05 HbA1c (%) 7.61 ± 2.01 8.26 ± 2.08 7.93 ± 2.06 > 0.05 HOMA2-IR 7.09 ± 5.08 6.86 ± 6.27 6.97 ± 5.69 > 0.05 Age (years) Gender As we all know, type diabetes mostly affects middle-aged people, although the prevalence of daytime disease is much earlier today On the other hand, type diabetes mellitus is a silent disease Patients are often diagnosed with high blood glucose levels or have had complications of diabetes > 0.05 mellitus The mean age of the study group was 62.12 ± 8.99 years, the youngest was 36 years old and the oldest was 81 years old The mean age of the study was similar to that of other Asian studies [6] but was higher in some studies [4, 5] This difference in age may be due to different purposes, 125 Journal of military pharmaco-medicine no7-2018 different designs, or characteristics of the different disease models of the studies On the team's anthropometric index, our results showed that the BMI was 22.96 ± 2.98 kg/m2 There was no difference in age, sex, BMI, HbA1c and HOMA2-IR in both men and women in our study, which would limit some of the confounding factors for comparison The results of the study were more accurate Characteristics of BMD in patients with type diabetes Table 2: BMD (g/cm²) Male (n = 76) Female (n = 75) Both (n = 151) p-values BMD total body 1.087 ± 0.097 0.942 ± 0.103 1.015 ± 0.123 < 0.01 BMD L1-L4 1.01 ± 0.189 0.857 ± 0.135 0.934 ± 0.181 < 0.01 BMD pelvis 1.02 ± 0.13 0.923 ± 0.135 0.976 ± 0.142 < 0.01 The BMD of L1-L4 and pelvic bone in men was higher than in females The difference was statistically significant with p < 0.01 The relationship between BMD and type diabetes has been studied extensively, particularly in relation to bone density in femoral neck and bone density in the lumbar spine Strotmeyer E.S et al (2004) reported that diabetes was an independent factor associated with bone density, particularly with increased pelvic density, which is independent of body composition and insulin concentrations [1] In this study, we did not compare the bone density between diabetic patients with nondiabetic patients, we compared bone density between men and women This is also a limitation of this study Results showed that BMD in men was higher than that of women in all positions as well as in the whole body According to Lili Ma (2012) [8], it has been shown that diabetic patients had a higher BMD than nondiabetics and that diabetes mellitus was also an independent factor associated with bile In addition, multivariate regression analyzes were able to determine that higher prevalence of BMI, high BMI and HbA1c in patients with diabetes was positively associated with increased bone density The mechanisms of these interrelationships are complex and there are many issues that are not clearly explained, and there may be many factors involved Characteristics of body composition Table 3: Body mass characteristics Features Male (n = 76) Female (n = 75) p-values Body fat (g) 8,282.122 ± 2,667.597 9,756.311± 2,806.796 < 0.01 Total body fat mass (g) 15,124.288 ± 4,440.377 18,041.951 ± 4,847.167 < 0.01 Total body lean mass (g) 40,957.312 ± 4,973.930 31,136.461 ± 4,266.716 < 0.01 Total body mass (g) 58,156.879 ± 8,400.475 50,681.417 ± 7,927.526 < 0.01 126 Journal of military pharmaco-medicine no7-2018 The body fat distribution, as well as total body fat of women were statistically significantly higher than men (p < 0.01) In contrast, lean and total body weight of men were significantly higher than women (p < 0.05) In this study, total body fat, body fat, abdominal fat in women with diabetes were higher than males with diabetes and the difference was statistically significant (p < 0.01), but in contrast the lean mass There was no difference in body fat percentage when compared to other studies [3, 5], though differing in BMI This can be explained by the effect of hormones on the development of fat mass The main role is to increase the sex hormones, especially the estrogen hormone of women to increase fat mass and body fat ratio Difference in total body mass, lean mass in male and female sex hormone-related is testosterone and estrogen In men, testosterone secretion by testes more than many times the ovaries One of the major roles of testosterone is to synthesize protein, increase muscle size and increase muscle strength Both of these hormones will decrease as age increases, resulting in reduced muscle mass and increased fat mass, so weight loss is very difficult Table 4: Association between body fat mass characteristics and HbA1c Features HbA1c < 7.0% HbA1c ≥ 7.0% p-values % fat trunk 30.38 ± 7.36 32.95 ± 7.43 0.035 Total body % fat 28.44 ± 6.73 31.43 ± 7.12 0.012 Total body fat mass (g) 16186.904 ± 4759.105 16788.65 ± 4922.08 0.464 Total trunk fat mass (g) 8747.613 ± 2759.758 9162.82 ± 2866.98 0.384 In group with HbA1c < 7%, the total body fat and body fat percentage were significantly (p < 0.05) lower than those without control of HbA1C ≥ 7% In contrast, total body fat and body fat in HbA1c < 7% were higher than HbA1c ≥ 7%, but not statistically significant Our results were similar to those of the GREAT2DO trial published in 2013 in the Diabetes Care [6] A National Health and Nutrition Examination Survey (NHANES), Julie K Bower et al (2017) In adults with high fat percent diabetes, high levels of HbA1C in men < 40 years and high body fat were associated with high levels of HbA1c in women of all ages [9] Thus, the percentage of fat gain is more positive for glycemic control than total fat mass Specifically, the lower the body fat, the better glycemic control to achieve the goal This also means that the body fat (abdominal area) is more difficult to control blood sugar may be due to increased insulin resistance Table 5: Correlation between BMD and HbA1c Index BMD (g/cm²) HbA1c < 7.0% (n = 54) HbA1c ≥ 7.0% (n = 97) p-values 1.0542 ± 0.1258 0.9937 ± 0.1177 0.005 127 Journal of military pharmaco-medicine no7-2018 In patients with good glycemic control (HbA1c < 7.0%), the BMD was (1.0542 ± 0.1258 g/cm²) higher than the control group with HbA1c ≥ 7.0% at 0.9937 ± 0.1177 g/cm² The difference was statistically significant with p < 0.01 In patients with type diabetes, a number of studies have shown that insulin levels can be a mediating part of the positive association between type diabetes and BMD Patients with type diabetes often have excess insulin In physiology, insulin has a competitive effect on bone due to its structural similarity with IGF-1 by interacting with IGF-1 receptors on bone marrow [2] IGF-1 is a very important signal for bone regeneration Studies in both humans and mice demonstrated a positive association between IGF-1 and BMD [1, 2, 4, 5] From this point of view, it can be hypothesized that insulin uptake may have a beneficial effect on bone formation and this difference by stimulating IGF-1 receptors for glucose uptake Some indirect effects of insulin on bone formation may be mediated by mediators such as amylin, osteoprotegerin, steroid hormone, and globulin hormonebinding hormone (SHBG) [1] In this study, bone density in the control group of HbA1c < 7.0% was significantly higher (p < 0.01) than in the control group of HbA1c ≥ 7.0% This result is similar to the results of the following studies: In the Rotterdam study, mean HbA1c was 7.5% in patients with type diabetes [4] Patients with type diabetes with HbA1c ≥ 7.5% had a higher fracture rate, 128 although BMD was higher, compared with those with type diabetes with HbA1c < 7.5% (HR = 1.54, 95%CI 1.04 - 2.29, adjusted for age, sex, height and weight) and conclusion that subjects with type diabetes and impaired glucose tolerance both have a higher BMD Longitudinal studies [7] have shown an increased risk of fractures with poor glycemic control People with baseline HbA1c levels of 10% (HR = 1.24; 1.02 - 1.49) and greater than 10% (HR = 1.32; 1.09 - 1.58) had a higher incidence of hip fracture than patients with HbA1c levels are - 7% The incidence of hip fracture was higher in the HbA1c group < 6% (HR = 1.19, 0.97 - 1.45) compared to - 7%, but the difference was not statistically significant Those with a - 8% HbA1c increased hip fracture rates (HR = 1.07, 0.92 - 1.25) compared with - 7% HbA1c Thus, good glycemic control is an increase in bone density, an increase in bone quality, thus reducing the risk of osteoporosis/fracture of the patient, even if aggressive control is more likely to occur Hypoglycemia leads to repercussions or fall fractures CONCLUSION In this study, in type diabetes patients, the BMD of L1-L4, pelvic and BMD total body in men were higher than in females The body fat distribution, total body fat of women were statistically significantly higher than men Good blood glucose control (HbA1c < 7%) is associated with a high percentage of fat mass, body fat distribution, and bone mineral density Journal of military pharmaco-medicine no7-2018 REFERENCES Strotmeyer E.S, Cauley J.A Schwartz A.V et al Diabetes is associated independently of body composition with BMD and bone volume in older white and black men and women: The health, aging, and body composition study J Bone Miner Res 2004, 19 (7), pp.1084-1091 Na Kyung Lee, Hideaki Sowa, Eiichi Hinoi, Mathieu Ferron et al Endocrine regulation of energy metabolism by the skeleton Cell 2007, August 10, 130 (3), pp.456-469 Michał Holecki, Andrzej Więcek Relationship between body fat mass and bone metabolism Pol Arch Med Wewn 2010, 120 (9), pp.361-367 I.I de Liefde, M van der Klift, C.E.D.H de Laet et al Bone mineral density and fracture risk in type diabetes mellitus: The Rotterdam study Osteoporos 2005, 16, pp.1713-1720 DOI 10.1007/s00198-005-1909-1 I.R Reid Relationships between fat and bone Osteoporos 2008, 19, pp.595-606 DOI 10.1007/s00198-007-0492-z Mavros Yorgi, Kay Shelley et al Changes in insulin resistance and HbA1c are related to exercise-mediated changes in body composition in older adults with type diabetes Interim outcomes from the GREAT2DO trial diabetes Care 2013, 36, pp.2372-2379 Li Chia-Ing, Liu Chiu-Shong et al Glycated hemoglobin level and risk of hip fracture in older people with type diabetes: A competing risk analysis of Taiwan diabetes cohort study J Bone Miner Res 2015, 30 (7), pp.1338-1346 Ma Lili, Oei Ling et al Association between bone mineral density and type diabetes mellitus: A meta-analysis of observational studies Eur J Epidemiol 2012), 27, pp.319-332 Bower Julie K, Meadows Rachel J et al The association of percent body fat and lean mass with HbA1c in US adults Journal of the Endocrine Society 2017, (6), pp.600-608 129 ... of military pharmaco-medicine no7 -20 18 - Survey BMD and body mass composition in patients with type diabetes - Study the relationship between BMD and body composition with HbA1c in patients with. .. was 7.5% in patients with type diabetes [4] Patients with type diabetes with HbA1c ≥ 7.5% had a higher fracture rate, 128 although BMD was higher, compared with those with type diabetes with HbA1c... be a mediating part of the positive association between type diabetes and BMD Patients with type diabetes often have excess insulin In physiology, insulin has a competitive effect on bone due to