The clinical use of Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) can be useful in identifying adults with type 1 diabetes at elevated risk for major osteoporotic fracture, according to results of a study published in Bone.

Elevated fracture risk in individuals with type 1 diabetes cannot be explained by BMD alone. While FRAX underestimates fracture prediction in people with type 2 diabetes, its utility has not been studied in type 1 diabetes.

To evaluate the association of FRAX without BMD and the risk for major osteoporotic fracture in type 1 diabetes, data from eligible 757 participants (type 1 diabetes n=346; control n=411) from the CACTI study were analyzed. Participants completed 4 visits over 18 years. The control group primarily consisted of people — spouses, friends, or neighbors — close to participants with type 1 diabetes who were not diagnosed with type 1 diabetes over the course of the study. There was no difference in body mass index between the 2 groups; however, the type 1 diabetes group had a significantly higher prevalence of rheumatoid arthritis (5.8% vs 1.2%; P =.0003) and history of fracture (64.4% vs 56%; P =.02).

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Over an average of 8.5 plus or minus 0.7 years of follow up for controls and 8.7 plus or minus 0.8 years of follow up for participants with type 1 diabetes, incident major ostoporotic fracture was reported in 45 participants, while incident hip fractures were reported in 6 participants. Incidence of new major osteoporotic fracture was significantly higher in the type 1 diabetes group (7.8% vs 4.4%; P =.048). When adjusting for age, sex, and diabetes status, FRAX score without BMD was the only variable significantly associated with risk for major osteoporotic fracture (hazard ratio, 1.08; 95% CI, 1.02-1.14; P =.006).

Study results indicate that FRAX without BMD may be a useful tool for therapeutic decision-making for individuals with type 1 diabetes given its powerful ability to predict major osteoporotic fracture.

Limitations to this study include the self-reporting nature of data collection regarding fractures and fracture history. Future research with longer follow-up periods is warranted.


Champakanath A, Keshawarz A, Pyle L, Snell-Bergeon JK, Shah VN. Fracture risk assessment (FRAX) without BMD and risk of major osteoporotic fractures in adults with type 1 diabetes. Published online August 21, 2020. Bone. doi: 10.1016/j.bone.2020.115614