***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE Individuals with type 2 diabetes have increased fracture risk despite higher bone mineral density ( BMD ) . Our aim was to examine the influence of glucose control on skeletal complications . RESEARCH DESIGN AND METHODS Data of 4,135 participants of the Rotterdam Study , a prospect i ve population -based cohort , were available ( mean follow-up 12.2 years ) . At baseline , 420 participants with type 2 diabetes were classified by glucose control ( according to HbA1c calculated from fructosamine ) , result ing in three comparison groups : adequately controlled diabetes ( ACD ; n = 203 ; HbA1c < 7.5 % ) , inadequately controlled diabetes ( ICD ; n = 217 ; HbA1c ≥7.5 % ) , and no diabetes ( n = 3,715 ) . Models adjusted for sex , age , height , and weight ( and femoral neck BMD ) were used to test for differences in bone parameters and fracture risk ( hazard ratio [ HR ] [ 95 % CI ] ) . RESULTS The ICD group had 1.1–5.6 % higher BMD , 4.6–5.6 % thicker cortices , and −1.2 to −1.8 % narrower femoral necks than ACD and ND , respectively . Participants with ICD had 47–62 % higher fracture risk than individuals without diabetes ( HR 1.47 [ 1.12–1.92 ] ) and ACD ( 1.62 [ 1.09–2.40 ] ) , whereas those with ACD had a risk similar to those without diabetes ( 0.91 [ 0.67–1.23 ] ) . CONCLUSIONS Poor glycemic control in type 2 diabetes is associated with fracture risk , high BMD , and thicker femoral cortices in narrower bones . We postulate that fragility in apparently “ strong ” bones in ICD can result from microcrack accumulation and /or cortical porosity , reflecting impaired bone repair CONTEXT Some but not all studies have shown higher rates of fracture in individuals with type 2 diabetes . OBJECTIVE The objective of the study was to determine the risk of fracture in postmenopausal women with type 2 diabetes and determine whether risk varies by fracture site , ethnicity , and baseline bone density . DESIGN , SETTING , AND PARTICIPANTS Women with clinical ly diagnosed type 2 diabetes at baseline in the Women 's Health Initiative Observational Cohort , a prospect i ve study of postmenopausal women ( n = 93,676 ) , were compared with women without diagnosed diabetes and risk of fracture overall and at specific sites determined . MAIN OUTCOME MEASURES All fractures and specific sites separately ( hip/pelvis/upper leg ; lower leg/ankle/knee ; foot ; upper arm/shoulder/elbow ; lower arm/wrist/h and ; spine/tailbone ) were measured . Bone mineral density ( BMD ) in a subset also was measured . RESULTS The overall risk of fracture after 7 yr of follow-up was higher in women with diabetes at baseline after controlling for multiple risk factors including frequency of falls [ adjusted relative risk ( RR ) 1.20 , 95 % confidence interval ( CI ) 1.11 - 1.30 ] . In a sub sample of women with baseline BMD scores , women with diabetes had greater hip and spine BMD . The elevated fracture risk was found at multiple sites ( hip/pelvis/upper leg ; foot ; spine/tailbone ) among black women ( RR 1.33 , 95 % CI 1.00 - 1.75 ) and women with increased baseline bone density ( RR 1.26 , 95 % CI 0.96 - 1.66 ) . CONCLUSION Women with type 2 diabetes are at increased risk for fractures . This risk is also seen among black and non-Hispanic white women after adjustment for multiple risk factors including frequent falls and increased BMD ( in a subset ) Type 2 diabetes mellitus ( T2DM ) is associated with an increased risk of fractures according to several studies . The underlying mechanisms remain unclear , although small case-control studies indicate poor quality of the cortical bone . We have studied a population -based sample of women aged 75 to 80 years in Gothenburg , r and omly invited from the population register .  Areal bone mineral density ( aBMD ) was measured by dual-energy X-ray absorptiometry ( Hologic Discovery A ) ,  bone microarchitecture by high-resolution peripheral quantitative computed tomography ( HR-pQCT ; ExtremeCT from Scanco Medical AG ) , and reference point indentation was performed with Osteoprobe ( Active Life Scientific ) . Women with T2DM ( n = 99 ) had higher aBMD  compared to controls ( n = 954 ) .  Ultradistal tibial and radial trabecular bone volume fraction ( + 11 % and + 15 % , respectively ) , distal cortical volumetric BMD ( + 1.6 % and + 1.7 % ) , cortical area ( + 11.5 % and + 9.3 % ) , and failure load ( + 7.7 % and + 12.9 % ) were higher in diabetics than in controls . Cortical porosity was lower ( mean ± SD : 1.5 % ± 1.1 % versus 2.0 % ± 1.7 % , p = 0.001 ) in T2DM in the distal radius but not in the ultradistal radius or the tibia . Adjustment for covariates ( age , body mass index , glucocorticoid treatment , smoking , physical activity , calcium intake , bone-active drugs ) eliminated the differences in aBMD but not in HR-pQCT bone variables . However , bone material strength index ( BMSi ) by reference point indentation was lower in T2DM ( 74.6 ± 7.6 versus 78.2 ± 7.5 , p < 0.01 ) , also after adjustment , and women with T2DM performed clearly worse in measures of physical function ( one leg st and ing : -26 % , 30-s chair-st and test : -7 % , timed up and go : + 12 % , walking speed : + 8 % ; p < 0.05 - 0.001 ) compared to controls . In conclusion , we observed a more favorable bone microarchitecture but no difference in adjusted aBMD in elderly women with T2DM in the population compared to nondiabetics . Reduced BMSi and impaired physical function may explain the increased fracture risk in T2DM . © 2016 American Society for Bone and Mineral Research The incidence of fragility fractures begins to increase in middle age . We investigated prospect ively risk factors for  low-energy fractures in men and women , and specifically for forearm , proximal humerus , vertebral , and ankle fractures . The population -based Malmö Preventive Project consists of 22,444 men and 10,902 women , mean age 44 and 50 years , respectively , at inclusion .  Baseline assessment included multiple examinations and lifestyle information . Mean follow-up was 19 and 15 years for men and women , respectively , regarding incident fractures . Fractures were ascertained from radiographic files . At least one low-energy fracture occurred in 1,262 men and 1,257 women . In men , the risk factors most strongly associated with low-energy fractures were diabetes [ relative risk ( RR ) 2.38 , confidence interval ( CI ) 95 % 1.65–3.42 ] and hospitalization for mental health problems ( RR 1.92 , CI 95 % 1.47–2.51 ) . Factors associated with mental health and lifestyle significantly increased the fracture risk in most of the specific fracture groups : hospitalizations for mental health problems ( RR 2.28–3.38 ) , poor appetite ( RR 3.05–3.43 ) , sleep disturbances ( RR 1.72–2.95 ) , poor self-rated health ( RR 1.80–1.83 ) , and smoking ( RR 1.70–2.72 ) . In women , the risk factors most strongly associated with low-energy fractures were diabetes ( RR 1.87 , CI 95 % 1.26–2.79 ) and previous fracture ( RR 2.00 , CI 95 % 1.56–2.58 ) . High body mass index ( BMI ) significantly increased the risk of proximal humerus and ankle fractures ( RR 1.21–1.33 ) while , by contrast , lowering the risk of forearm fractures ( RR 0.88 , CI 95 % 0.81–0.96 ) . Risk factors for fracture in middle-aged men and women are similar but with gender differences for forearm , vertebral , proximal humerus , and hip fracture whereas risk factors for ankle fractures differ to a certain extent . The risk-factor pattern indicates a generally impaired health status , with mental health problems as a major contributor to fracture risk , particularly in men Bone density , bone turnover and fracture susceptibility were evaluated in 1,132 r and omly recruited women , all 75 years old . Seventy-four of the women had diabetes , while 1,058 women did not .  Areal bone mineral density ( aBMD ) of the hip and lumbar spine was investigated by dual energy X-ray absorptiometry ( DXA ) , and bone mass of the calcaneus was measured by ultrasound . Urinary deoxypyridinoline/creatinine ( U-DPD/Crea ) and serum C-terminal cross-linked telopeptide of type 1 collagen ( S-CTX ) were assessed as markers of bone resorption . Serum bone-specific alkaline phosphatase ( S-bone ALP ) and serum osteocalcin ( S-OC ) were assessed as markers of bone formation . Also , serum 25(OH ) vitamin D and serum parathyroid hormone ( S-PTH ) were assessed . Fracture susceptibility was evaluated retrospectively and prospect ively for up to 6.5 years . In diabetic women , the aBMD of the femoral neck was 11 % higher ( p < 0.001 ) , and BMD of the lumbar spine was 8 % higher ( p = 0.002 ) than in non-diabetic women . There was no difference in bone mass by ultrasound of the calcaneus . Women with diabetes had higher BMD of the femoral neck ( p < 0.001 ) and lumbar spine ( p = 0.03 ) also after correction for differences in body weight . In diabetic women , U-DPD/Crea , S-CTX , and S-OC were decreased when compared with non-diabetic women ( p = 0.001 or less ) . After correction for covariance of body weight and plasma creatinine , S-CTX ( p < 0.001 ) and S-OC ( p < 0.001 ) were still lower in the diabetic women . Diabetic patients had hypovitaminosis D ( p = 0.008 ) , a difference explained by differences in time spent outdoors and body weight . S-PTH did not differ between the groups . Women with diabetes had no more lifetime fractures ( 52 % ) than women without diabetic disease ( 57 % ) , ( p = 0.31 ) . This study shows that elderly women with diabetes and without severe renal insufficiency have high bone mass and low bone turnover . The high bone mass and low bone turnover is not likely to have a strong influence on fracture susceptibility CONTEXT Type 2 diabetes mellitus ( DM ) is associated with higher bone mineral density ( BMD ) and paradoxically with increased fracture risk . It is not known if low BMD , central to fracture prediction in older adults , identifies fracture risk in patients with DM . OBJECTIVE To determine if femoral neck BMD T score and the World Health Organization Fracture Risk Algorithm ( FRAX ) score are associated with hip and nonspine fracture risk in older adults with type 2 DM . DESIGN , SETTING , AND PARTICIPANTS Data from 3 prospect i ve observational studies with adjudicated fracture outcomes ( Study of Osteoporotic Fractures [ December 1998-July 2008 ] ; Osteoporotic Fractures in Men Study [ March 2000-March 2009 ] ; and Health , Aging , and Body Composition study [ April 1997-June 2007 ] ) were analyzed in older community-dwelling adults ( 9449 women and 7436 men ) in the United States . MAIN OUTCOME MEASURE Self-reported incident fractures , which were verified by radiology reports . RESULTS Of 770 women with DM , 84 experienced a hip fracture and 262 a nonspine fracture during a mean ( SD ) follow-up of 12.6 ( 5.3 ) years . Of 1199 men with DM , 32 experienced a hip fracture and 133 a nonspine fracture during a mean ( SD ) follow-up of 7.5 ( 2.0 ) years . Age-adjusted hazard ratios ( HRs ) for 1-unit decrease in femoral neck BMD T score in women with DM were 1.88 ( 95 % confidence interval [ CI ] , 1.43 - 2.48 ) for hip f 
    Output:
    
Conclusion The risk of fractures is increased in diabetes at the ankle and decreased at the wrist .
The same pattern is observed in obesity .
Although bone microarchitectural features are different in obesity and diabetes , the epidemiology of peripheral fractures is similar in both diseases suggesting that microarchitecture may not be the major determinant of peripheral fractures in these population