Accepted Manuscript

Association between basal metabolic function and bone metabolism in

postmenopausal women with type 2 diabetes

Makiko Ogata, Risa Ide, Miho Takizawa, Mizuho Tanaka, Tamaki Tetsuo, Asako
Sato, Naoko Iwasaki, Yasuko Uchigata

PII: S0899-9007(15)00282-8
DOI: 10.1016/[Link].2015.06.012
Reference: NUT 9561

To appear in: Nutrition

Received Date: 12 February 2015

Revised Date: 8 June 2015
Accepted Date: 18 June 2015

Please cite this article as: Ogata M, Ide R, Takizawa M, Tanaka M, Tetsuo T, Sato A, Iwasaki N,
Uchigata Y, Association between basal metabolic function and bone metabolism in postmenopausal
women with type 2 diabetes, Nutrition (2015), doi: 10.1016/[Link].2015.06.012.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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 ACCEPTED MANUSCRIPT

Association between basal metabolic function and bone metabolism in

postmenopausal women with type 2 diabetes

Makiko Ogata1), Risa Ide1), Miho Takizawa1), Mizuho Tanaka1), Tamaki Tetsuo1),

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Asako Sato2), Naoko Iwasaki1), Yasuko Uchigata1)

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1) Diabetes Center, Tokyo Women’s Medical University, Tokyo, Japan

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2) Clinical Laboratory, Tokyo Women’s Medical University, Tokyo Japan

Corresponding author: Makiko Ogata

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8-1, Kawada-cho, Shinjyuku-ku, 162-8666

Tokyo, Japan
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Tel: +81-3-3353-8111 Ext. 27011

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Fax: +81-3-3358-1941
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Email: mogatamd@[Link]
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Abstract

Objective: Diabetes is a risk factor for osteoporosis, and glycemic control is critical

during osteoporosis treatment in patients with type 2 diabetes (T2D). However, diabetic

therapies have potentially adverse effects on bone metabolism. In addition, biomarkers

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for bone metabolism are directly affected by osteoporosis drug therapies. This study

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examined resting energy expenditure (REE) and respiratory quotient (RQ) as indices of

bone metabolism in postmenopausal Japanese women with T2D.

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Methods: Forty-six postmenopausal Japanese women with T2D were examined.

Procollagen type 1 N-terminal propeptide (P1NP, a fasting serum bone formation

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marker) and carboxy-terminal collagen crosslinks-1 (CTX-1, a resorption marker) were
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evaluated, along with intact parathyroid hormone, 25-hydroxyvitamin D (25[OH]D),

urine microalbumin, motor nerve conduction velocity, sensory nerve conduction

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velocity, R-R interval, body composition, REE, RQ, and bone mineral density at the
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non-dominant distal radius.

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Results: The mean T-score was low with high variance (–1.7 ± 1.6), and 18 patients

(39%) met the criteria for osteoporosis. REE was positively correlated with body mass
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index (β = 0.517, r2 = 0.250), serum calcium (β = 0.624, r2 = 0.200), HbA1c for the

previous 6 months (β = 0.395, r2 = 0.137), and the serum P1NP/CTX-1 ratio (β =

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0.380, r2 = 0.144). RQ was positively correlated with serum 25[OH]D (β = 0.387, r2 =

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0.131).

Conclusions: The basal metabolic rate and diabetic pathophysiology are interrelated

with bone turnover.

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Keywords: Diabetes, Menopause, Resting energy expenditure, Bone metabolism,

Osteoporosis

Abbreviations

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ALP, alkaline phosphatase; BMI, body mass index; BMD, bone mineral density; Ca,

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calcium; CTX-1; carboxy-terminal collagen crosslinks-1; CPR, C peptide; DPPIV-I,

dipeptidyl-peptidase IV inhibitor; HbA1c, glycated hemoglobin A1c, HDL, high-density

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lipoprotein; LDL, low-density lipoprotein; MCV, Motor nerve conduction velocity;

OHA, oral hypoglycemic agent; P, phosphate; P1NP, procollagen type 1 N-terminal

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propeptide; iPTH, intact parathyroid hormone; REE, resting energy expenditure; RQ,
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respiratory quotient; SCV, sensory nerve conduction velocity; SU, sulfonylurea; T2D,

type 2 diabetes; 25[OH]D, 25-hydroxyvitamin D.

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Introduction
The risk of fracture is particularly high among patients with diabetes [1].

Although the risk in patients with type 1 diabetes (T1D) is attributed to their lower

maximal bone mass (due to their insulin deficiency), patients with type 2 diabetes

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(T2D) typically have a high bone mineral density (BMD) [2, 3]. Therefore, the

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etiology of osteoporosis is thought to differ between patients with insulin deficiency

and insulin resistance. Bone metabolism and blood glucose metabolism are considered

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closely related [4], and low bone mass is thought to be due to unbalanced bone

remodeling, which involves both resorption of the bone matrix by osteoclasts and bone

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formation by osteoblasts [5]. In addition, the finding that fat regulates bone
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metabolism has been viewed as an indication that bone metabolism might regulates

some aspects of energy metabolism via a feedback loop [6]. Moreover, insulin
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resistance in patients with metabolic syndrome is associated with their low resting
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energy expenditure (REE)/body weight ratio [7], and fracture risk is high in these
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patients [8, 9]. The metabolic effects, with the subsequent changes in body mass index

(BMI), can be predicted using the respiratory quotient (RQ), which represents inner
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respiration, and REE in patients with T2D [10]. Furthermore, REE is more closely

associated with BMD (compared to BMI) in African American women [11]. Moreover,
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osteocalcin, leptin (a hormone that is derived from fat) and serotonin (an anorexigenic
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neurotransmitter in the brain) are closely related with bone remodeling and energy

metabolism [6, 12-14]. When taken together, these findings suggest that basal

metabolism in patients with T2D may be involved in bone metabolism.

In late postmenopausal women, vertebral fracture was well predicted by

bone turnover markers, independent of BMD, over a 10-year follow-up period [15].

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Thus, serum biochemical markers of bone turnover should predict the risk of vertebral

fracture in patients with T2D [16]. In addition, women with T2D have a particularly

high risk of femoral neck fracture, and it has recently been reported that suppression of

bone turnover increases the fracture risk in postmenopausal women with T2D [17]. It

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is also well known that the basal metabolism in postmenopausal women with diabetes

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is markedly low [18]. Thus, reduced bone metabolism due to a lower basal metabolic

ratio is a possible fracture risk factor in postmenopausal women with T2D.

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Furthermore, markers for bone turnover can be used to evaluate the efficacy of a drug

during osteoporosis treatment, although diabetes may also alter bone metabolism,

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which may then affect bone turnover markers [19, 20].
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In this study, we aimed to examine the relationship between bone metabolism

and basal metabolic function in postmenopausal women with T2D, and to test the
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hypothesis that basal metabolism is a useful marker for evaluating bone health.
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Materials and Methods

Patients
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We initially recruited 56 postmenopausal Japanese women (>50 years old) with

T2D, who had attended our clinic for at least 1 year. Ten patients were excluded from
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the study after a careful examination of their medical histories, based on the intake of
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dietary supplements in the previous 3 months (e.g., vitamins), or possible latent adult

autoimmune diabetes with the presence of autoimmune antibodies, such as anti-

glutamic acid decarboxylase antibodies. The remaining 46 patients had no signs of

complications, were not overtly proteinuric, and exhibited no symptoms of major

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diseases other than hypertension, dyslipidemia, and obesity (BMI ≥30 kg/m2).

Written informed consent was obtained from all patients prior to their

participation. The study was approved by the ethics committee of the Tokyo Women’s

Medical University (IRB number: 2396).

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Measurements

To evaluate orthostatic hypotension, blood pressure was measured in the supine

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and standing positions within a 3-min interval. Blood samples were collected after a

10-h overnight fast, and were used for all the tests that were performed in this study.

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Serum levels of P1NP and CTX-1 were measured at Roche Diagnostics (Tokyo, Japan)
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in a blinded manner. Serum levels of intact parathyroid hormone (iPTH), 25-

hydroxyvitamin D (25[OH]D), calcium, and phosphate were evaluated in our hospital

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using aliquots of the same serum samples. General serum tests were also performed to
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measure aspartate transaminase, alanine transaminase, cholesterol, triglyceride, and

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creatinine levels. Microalbumin content in the patients’ first morning urine samples

was used to evaluate complications. Motor nerve conduction velocity (MCV) and
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sensory nerve conduction velocity (SCV) were calculated using the Neuropack X1

system (Nihon Kohden, Tokyo, Japan). The R-R interval was calculated as the
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maximum difference in pulses/min under deep breathing conditions.

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Body composition was calculated via the impedance method using a body

composition analyzer (Tanita, Tokyo, Japan). REE and RQ were calculated over a 20-

min period via respiratory gas analysis in a thermoneutral environment using Vmax

Spectra indirect calorimetry (Cardinal Health, OH, USA). A diagnosis of retinopathy

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was recorded within the 6 months prior to the patient’s participation in this study.

BMD was evaluated using dual-energy X-ray absorptiometry (Hologic, Bedford, MA,

USA) at the non-dominant distal radius. The cortex of the radial bone is thinner than

that of the lumbar bone, which causes the radial bone to be fractured more frequently.

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Furthermore, bone mineral density in the non-dominant distal radius has been used to

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screen for osteoporosis [21-23], and it is common for the first fracture to occur in the

distal radius [21, 24, 25]. Although BMD in the lumbar or femoral neck can increase,

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BMD in the distal radius is not affected by poor blood glucose control [26]. Therefore,

the BMD in the distal radius was considered the most appropriate screening tool for

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osteoporosis. The T-score described the number of standard deviations by which an
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individual’s BMD differed from the mean value that is expected in young healthy

individuals at the same point.

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Statistical analysis
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The results were expressed as mean ± standard deviation. All analyses were

performed using SPSS software (version 21.0, SPSS, Chicago, IL, USA). Intergroup
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comparisons were performed using Student’s t-test (with vs. without a history of minor

fracture, or low vs. normal 25[OH]D levels). To evaluate the relationship between
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basal metabolism and bone metabolism, correlation analysis was performed between
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the various factors. Regression analysis was performed between each pair of variables

that exhibited a significant correlation, and all coefficients for determination data were

adjusted (r2). The contributions of blood glucose control, basal metabolism, and aging

to bone metabolism were evaluated for each relevant biological parameter that had a

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significance of p < 0.1 in the univariate analysis, and these were assessed in 3 multiple

regression analysis models. Differences were considered statistically significant at a p-

value of <0.05.

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Results

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Patient characteristics

The patients’ clinical information is listed in Table 1; the mean age was 65.0 ±

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5.9 years, mean BMI was 24.5 ± 3.6 kg/m2, and mean duration of diabetes was 15.8 ±

8.7 years. It is notable that none of the patients had been diagnosed with osteoporosis,

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although 10 patients had a history of bone fracture. Among these patients, 9 had non-
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traumatic fractures. The patients fractured their arms, lower legs, or toes, and 1 had

fractured her lower leg and finger twice. The MCVs in the ulnar and peroneal nerves
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were 55.0 ± 4.5 m/s (normal: 58.2 ± 4.7 m/s [27]) and 46.3 ± 5.0 m/s (normal: 47.2 ±
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3.7 m/s), respectively. The SCVs in the ulnar and sural nerves were 51.5 ± 3.7 m/s
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(normal: 55.0 ± 3.8 m/s) and 48.9 ± 7.7 m/s (normal: 50.8 ± 5.1 m/s), respectively.

Regarding respiratory load, the mean R-R interval was shorter than the predicted age-
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related values in 5 patients, and no significant differences were observed between the

blood pressures in the decubitus and standing positions for all patients. There was no
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significant difference in the neurological outcomes for patients with or without a

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history of fracture.

Bone metabolism

The mean BMD and T-score in the tracheal bones were 0.473 ± 0.07 g/cm2 and

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−1.76 ± 1.52, respectively. Eighteen patients (39%) had a T-score of less than −2.5,

and were diagnosed with osteoporosis [28]. The serum levels of the bone metabolism

markers are listed in Table 1. The mean serum levels of CTX-1 and P1NP were lower

in our patients, compared to the values that have been reported in normal

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postmenopausal women (CTX-1: 0.36 ± 0.13 ng/mL vs. 0.56 ± 0.23 ng/mL, P1NP:

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37.6 ng/mL vs. 45.05 ng/mL) [20].

The CTX-1 levels were significantly and negatively correlated with the

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patients’ initial HbA1c levels (r = −0.397, p = 0.006) and average HbA1c levels for the

previous 6 months (r = −0.385, p = 0.008) (Fig. 1A); the CTX-1 levels were positively

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correlated with P1NP levels (r = 0.645, p < 0.001). In addition, the P1NP levels were
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significantly and negatively correlated with the patients’ initial HbA1c levels (r =

−0.41, p = 0.005) and duration of diabetes (r = −0.36, p = 0.01), and were significantly
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and positively correlated with their 25[OH]D levels (r = 0.321, p = 0.03) and CTX-1
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levels (r = 0.645, p < 0.0001). The P1NP and CTX-1 levels were strongly correlated
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with each other (r = 0.645, p < 0.0001), although neither was correlated with BMD

(P1PN: r = 0.063, p = 0.679; CTX-1: r = –0.16, p = 0.288). The ratio of P1NP to CTX-
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1 (P1NP/CTX-1), which is an indicator of bone turnover, was significantly correlated

with BMI (r = 0.455, p = 0.001), RQ (r = 0.336, p = 0.02), REE (r = 0.38, p = 0.009),

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and BMD (r = 0.321, p = 0.029); P1NP/CTX-1 was negatively correlated with iPTH (r
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= −0.326, p = 0.027). However, P1NP/CTX-1 was not correlated with iPTH after

adjusting for REE, BMD, and serum calcium levels.

Although the serum calcium and iPTH levels were normal in all patients, the

25[OH]D levels were <20 ng/mL in 23 patients (50%). The characteristics of the

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patients with low vitamin D levels are shown in Table 2. These patients did not

habitually walk for more than 30 min twice per week, had a significantly lower C-

peptide response, and had a significantly increased insulin dependency (p < 0.01).

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Basal metabolism and RQ

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The patients’ REE was less than the value that was predicted using the

modified Harris Benedict equation (940.5 ± 155.7 kcal vs. 1,176.7 ± 98.3 kcal; p <

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0.0001), and the mean RQ was 0.88 ± 0.10. REE was significantly associated with

BMI (p < 0.0001), serum calcium (p < 0.0001), and HbA1c at 6 months (p = 0.007).

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Although REE was not correlated with CTX-1 or P1NP, it was significantly correlated
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with P1NP/CTX-1 (r = 0.38, p = 0.009) (Fig. 1B). After adjusting for BMI,

P1NP/CTX-1, and HbA1c levels at 6 months, multiple regression analysis revealed

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that REE was significantly correlated with serum calcium levels (p = 0.002).
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Furthermore, RQ was weakly correlated with P1NP/CTX-1 (r = 0.336, p = 0.02) and

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25[OH]D levels (r = 0.387, p = 0.008), and was strongly correlated with 25[OH]D

after adjusting for P1NP/CTX-1 (Fig. 1C).

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Multiple regression analysis models

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All single correlations were confirmed by linear regression analysis (Table 3),
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and the multiple regression analysis models were used to evaluate the relationships

between basal metabolism, blood glucose control, bone metabolism, and BMD. The

multiple linear regression analysis models that were used to evaluate REE, blood

glucose control for the previous 6 months, and age are shown in Table 4. The mean

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HbA1c levels in the previous 6 months were negatively correlated with both CTX-1

and P1NP, after adjusting for REE and age. REE was correlated with the P1NP/CTX-1

ratio, and BMD was correlated with age.

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Discussion

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In the present study of postmenopausal women with T2D who were not taking

supplements, all patients had attended our hospital for at least 1 year, with continuous

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diabetic treatment for at least 3 years without severe complications. As expected, the

basal metabolic rate was associated with markers of bone turnover and serum calcium

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levels. In addition, the 25[OH]D levels were correlated with RQ, which is the index of
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the internal respiration that is caused by oxidation of carbohydrates, protein, or fat.

These results demonstrate that REE and RQ are important parameters to consider
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when evaluating osteoporosis in patients with postmenopausal diabetes.

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Osteoporosis is defined using a combination of BMD and bone quality. Bone

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quality is defined using the characteristics of the bone matrix, such as

microarchitecture, bone turnover, micro-damage accumulation, the degree of

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calcification, and collagen, which can be clinically assessed by measuring bone

metabolism using biochemical markers of bone turnover [29, 30-32]. These makers are
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also associated with an increased risk of osteoporotic fracture in postmenopausal

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women, independent of BMD [33]. However, BMD is not a definitive predictive

marker of bone fracture in patients with T2D [2], although serum biochemical markers

of bone turnover (for both formation and resorption) are accurate predictors of

osteoporosis or osteopenia in women [16]. Among the many biochemical markers of

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bone turnover, CTX-1 and P1NP are markers for the resorption and formation of

collagen, and are expected to reflect the early changes during bone turnover [34].

Our patients’ REE was lower than the predicted value that was calculated

using the modified Harris Benedict equation. However, the REE in Asian women is

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usually lower than that in Caucasian women, when measured using indirect calorimetry,

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relative to the expenditures that are calculated using prediction equations [35].

Furthermore, among women who are 30–60 years old, the predictive equation provides

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an overestimation of 9.0% (relative to the actual basal metabolic rate) [36]. Therefore,

although the REE in this study was relatively low, this finding is adequate for our

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purposes. Nevertheless, it is important to determine the basal metabolism using indirect
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calorimetry for accurate evaluations in these subjects. Although we observed that the

BMD of the distal radius was correlated with BMI, age, fat mass, and P1NP/CTX-1, it
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was not correlated with REE, CTX-1, or P1NP. This is likely explained by the fact that
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several metabolic factors, such as REE, CTX-1, and P1NP, were correlated with blood
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glucose control in the previous 6 months.

REE is closely related to leptin [37], which is an adipokines that is secreted by

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fat tissue, which controls energy homeostasis [38, 39]. Peripheral leptin acts on the

skeleton through the leptin receptor of osteoblasts [40]. However, peripheral leptin
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levels are not correlated with BMD in postmenopausal women [41]. Therefore, central
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leptin function is thought to influence bone regulation, and also regulates energy

expenditure in leptin receptor knockout mouse [42]. In contrast, blockage of leptin

signaling in a murine model inhibited bone mass accrual by up-regulating sympathetic

activity, independent of any change in appetite or energy expenditure [43]. Serotonin

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has also recently been reported to be a key regulator of bone metabolism through leptin

[44-46]. Inhibition of peripheral serotonin synthesis reduces obesity and metabolic

dysfunction, and increases REE [47]. Moreover, leptin and serotonin have been reported

to be dysregulated in diabetes [48-51]. Thus bone, glucose, and energy metabolism must

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be influenced by each other in the peripheral and neuro-central systems. Furthermore,

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REE is a parameter that is influenced directly by all of these factors in this energy-bone

cascade, and will exhibit values that reflect these factors’ function in this cascade.

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In the present study, we demonstrated that the patients’ REE was correlated

with the ratio of a bone collagen formation marker (P1NP) to a bone collagen

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resorption marker (CTX-1), which indicates active bone turnover. Our data are the first
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to demonstrate the direct correlation of bone metabolism with energy expenditure in

patients with T2D. In addition, REE was positively correlated with BMI, initial HbA1c
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levels, and HbA1c levels at 6 months. Finally, CTX-1 and P1NP were positively
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correlated with each other, and both factors were negatively correlated with average
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HbA1c in the previous 6 months. Taken together, our findings indicate that bone

turnover is correlated with the patients’ basal metabolic rate, and ultimately with their
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blood glucose control. These findings also imply that poor glycemic control may lead

to low bone turnover in patients with well-controlled T2D.

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Although CTX-1 is negatively correlated with P1NP, and tends to be negatively

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correlated with HbA1c [52], P1NP decreases in postmenopausal women with T2D [53].

Interestingly, low bone turnover and bone deficiency in T2D is thought to be caused by

elevated glycemic levels, based on a study of bone metabolic markers [54]. In addition,

although postmenopausal women exhibit high levels of bone resorption markers [15,

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55], given their high bone turnover, it has recently been reported that suppression of

bone turnover increases the fracture risk in postmenopausal women with T2D [17, 54],

which is consistent with our results. Furthermore, although bisphosphonate (an inhibitor

of bone resorption) is typically used to treat osteoporosis, it is less effective for patients

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with T2D [56]. Moreover, bone formation is reduced by bisphosphonates with bone

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resorption in a mouse model of diabetes [57]. Thus, the association of CTX-1 (a bone

resorption factor) with glycemic control and low bone turnover at the pretreatment stage,

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as reported in the present study, may explain why bisphosphonate is ineffective in

patients with osteoporosis and poorly controlled diabetes. In this context, good glycemic

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control and increased basal metabolism are desirable for patients with postmenopausal
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diabetes. However, their clinical management is complex, as strict dietary regimens may

lead to decreased fat mass, BMD, and REE [58-61], and tight glycemic control with
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aggressive diabetes drug therapies may result in increased fat mass and BMD [62-64]
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without any increase in REE [65, 66], thereby increasing the risk of developing
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atherosclerosis [67-69]. Although insulin therapy may improve bone metabolism in

patients with insulin-requiring diabetes [70], early initiation of insulin therapy decreases
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patients’ REE [68, 71, 72]. Both fat mass and REE were correlated with the ratio of

bone formation to bone resorption marker, whereas fat mass was correlated with BMD
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and was not correlated with HbA1c. However, REE was correlated with HbA1c and was
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not correlated with BMD. Thus, bone metabolic markers, which indicate bone quality,

are considered better markers of osteoporosis, compared to BMD, especially in T2D [15,

16]. Nutritional and bone turnover markers is useful predictors of bone loss in elderly

women [73], although these bone metabolic markers are likely altered by drug therapies

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for osteoporosis [74, 75]. Therefore, the levels of REE and RQ are likely useful for

evaluating bone metabolism and therapeutic strategies for controlling blood glucose

levels in patients with diabetes.

A correlation between sensory nerve function and bone volume has been

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reported in a mouse model and in elderly humans [76, 77], and the relationship

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between diabetic polyneuropathy and non-traumatic fractures has also been reported

[78]. However, MCV and SCV (as indicators of diabetic neuropathy) were not

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correlated with bone turnover markers in the present study. Thus, it appears that the

correlation between peripheral nerve function and bone turnover may be weak in

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elderly female patients with diabetes, and this theory is consistent with the findings of
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a previous report [79]. Alternatively, our screening tests for sensory and autonomic

nervous function may not be suitable for evaluating the subtle changes in nervous
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function that occur in diabetic neuropathy, as these tests are commonly used for the
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general evaluation of diabetic neuropathy. However, the patients’ MCV in the ulnar
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and peroneal nerves and SCV in the ulnar and sural nerves were below the normal

ranges for Japanese persons of a similar age, which suggests that they had diabetic
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neuropathy [27, 80].

Patients with diabetes are known to have low vitamin D levels, and the
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frequency of hypovitaminosis D in our subjects was similar to that in a previous

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Japanese study [81]. Furthermore, we found that 25[OH]D levels were correlated with

RQ, which is an index of internal respiration that indicates the nutrient source of

energy [82]. The relationship between 25[OH]D and RQ may be complex, although

several speculations can be considered. For example, a low RQ indicates reduced lipid

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oxidation [83] in patients with low vitamin D, although 25[OH]D levels are positively

associated with lipid metabolism [84, 85]. In addition, patients with T2D and low

vitamin D levels have significantly lower C-peptide levels (compared to patients with

normal vitamin D levels), and these patients require insulin more often [86]. Thus, the

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pathogenesis of diabetes reflects decreased insulin secretion and sensitivity. Therefore,

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our results indicate that RQ (internal respiration) is correlated with serum vitamin D

levels, which can predict fracture, and that these levels are also correlated with BMI,

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insulin sensitivity, and pancreatic β cell dysfunction in the prediabetic state [87].

The association of REE with bone metabolism in this study may indicate

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that these factors are regulated via neurotransmitters and adipocyte hormones,
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although further studies are needed to evaluate this hypothesis.
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Conflict of Interest
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The authors have no conflicts of interest to declare.

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Acknowledgements
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We thank Prof. T. Matsumoto for his advice, Ms. M. Tomioka for her assistance with the

data analyses, and Mr. M. Tomoda for de-identifying the patients’ data. This study was
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partially supported by Grant-in-Aids (22510214) for Scientific Research from MEXT,

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the National Center for Global Health and Medicine (21A114) from the MHLW of

Japan (N.I.), and a research grant from Lilly (M.O.).

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References

[1] Nicodemus KK, Folsom AR, Study IWsH. Type 1 and type 2 diabetes and incident

hip fractures in postmenopausal women. Diabetes Care. 2001;24:1192-7.

[2] Vestergaard P. Discrepancies in bone mineral density and fracture risk in patients

PT
with type 1 and type 2 diabetes--a meta-analysis. Osteoporos Int. 2007;18:427-44.

RI
[3] Yamamoto M, Yamaguchi T, Yamauchi M, Kaji H, Sugimoto T. Diabetic patients

have an increased risk of vertebral fractures independent of BMD or diabetic

SC
complications. J Bone Miner Res. 2009;24:702-9.

[4] de Paula FJ, Horowitz MC, Rosen CJ. Novel insights into the relationship between

U
diabetes and osteoporosis. Diabetes Metab Res Rev. 2010;26:622-30.
AN
[5] Raggatt LJ, Partridge NC. Cellular and molecular mechanisms of bone remodeling. J

Biol Chem. 2010;285:25103-8.

M

[6] Lee NK, Sowa H, Hinoi E, Ferron M, Ahn JD, Confavreux C, et al. Endocrine
D

regulation of energy metabolism by the skeleton. Cell. 2007;130:456-69.

TE

[7] Buscemi S, Verga S, Caimi G, Cerasola G. A low resting metabolic rate is associated

with metabolic syndrome. Clin Nutr. 2007;26:806-9.

EP

[8] Ahmed LA, Schirmer H, Berntsen GK, Fønnebø V, Joakimsen RM. Features of the

metabolic syndrome and the risk of non-vertebral fractures: the Tromsø study.
C

Osteoporos Int. 2006;17:426-32.

AC

[9] Srikanthan P, Crandall CJ, Miller-Martinez D, Seeman TE, Greendale GA, Binkley N,

et al. Insulin resistance and bone strength: findings from the study of midlife in the

United States. J Bone Miner Res. 2014;29:796-803.

[10] Gonzalez C, Fagour C, Maury E, Cherifi B, Salandini S, Pierreisnard A, et al. Early

17
 ACCEPTED MANUSCRIPT

changes in respiratory quotient and resting energy expenditure predict later weight

changes in patients treated for poorly controlled type 2 diabetes. Diabetes Metab. 2014.

[11] Afghani A, Barrett-Connor E, Wooten WJ. Resting energy expenditure: a better

marker than BMI for BMD in African-American women. Med Sci Sports Exerc.

PT
2005;37:1203-10.

RI
[12] Ducy P, Karsenty G. The two faces of serotonin in bone biology. J Cell Biol.

2010;191:7-13.

SC
[13] Ducy P. The role of osteocalcin in the endocrine cross-talk between bone

remodelling and energy metabolism. Diabetologia. 2011;54:1291-7.

U
[14] García-Martín A, Reyes-García R, Avila-Rubio V, Muñoz-Torres M. Osteocalcin: a
AN
link between bone homeostasis and energy metabolism. Endocrinol Nutr. 2013;60:260-3.

[15] Tamaki J, Iki M, Kadowaki E, Sato Y, Chiba Y, Akiba T, et al. Biochemical markers
M

for bone turnover predict risk of vertebral fractures in postmenopausal women over
D

10 years: the Japanese Population-based Osteoporosis (JPOS) Cohort Study. Osteoporos

TE

Int. 2013;24:887-97.

[16] Iki M, Morita A, Ikeda Y, Sato Y, Akiba T, Matsumoto T, et al. Biochemical

EP

markers of bone turnover may predict progression to osteoporosis in osteopenic women:

the JPOS Cohort Study. J Bone Miner Metab. 2007;25:122-9.

C

[17] Jiajue R, Jiang Y, Wang O, Li M, Xing X, Cui L, et al. Suppressed bone turnover
AC

was associated with increased osteoporotic fracture risks in non-obese postmenopausal

Chinese women with type 2 diabetes mellitus. Osteoporos Int. 2014;25:1999-2005.

[18] Duval K, Prud'homme D, Rabasa-Lhoret R, Strychar I, Brochu M, Lavoie JM, et al.

Effects of the menopausal transition on energy expenditure: a MONET Group Study. Eur

18
 ACCEPTED MANUSCRIPT

J Clin Nutr. 2013;67:407-11.

[19] Blumsohn A, Marin F, Nickelsen T, Brixen K, Sigurdsson G, González de la Vera J,

et al. Early changes in biochemical markers of bone turnover and their relationship with

bone mineral density changes after 24 months of treatment with teriparatide. Osteoporos

PT
Int. 2011;22:1935-46.

RI
[20] Nomura Y, Yoshizaki A, Yoshikata H, Kikuchi R, Sakakibara H, Chaki O, et al.

Study of the distribution by age group of serum cross-linked C-terminal telopeptide of

SC
type I collagen and procollagen type I N-propeptide in healthy Japanese women to

establish reference values. J Bone Miner Metab. 2013;31:644-51.

U
[21] Mallmin H, Ljunghall S. Distal radius fracture is an early sign of general
AN
osteoporosis: bone mass measurements in a population-based study. Osteoporos Int.

1994;4:357-61.
M

[22] Garnero P, Sornay-Rendu E, Duboeuf F, Delmas PD. Markers of bone turnover

D

predict postmenopausal forearm bone loss over 4 years: the OFELY study. J Bone Miner
TE

Res. 1999;14:1614-21.

[23] Duboeuf F, Sornay-Rendu E, Garnero P, Bourgeaud-Lignot A, Delmas PD. Cross-

EP

sectional and longitudinal assessment of pre- and postmenopausal bone loss with a

portable forearm X-ray device: the Ofely study. Bone. 2000;26:131-5.

C

[24] Kelsey JL, Browner WS, Seeley DG, Nevitt MC, Cummings SR. Risk factors for
AC

fractures of the distal forearm and proximal humerus. The Study of Osteoporotic

Fractures Research Group. Am J Epidemiol. 1992;135:477-89.

[25] FitzGerald G, Boonen S, Compston JE, Pfeilschifter J, LaCroix AZ, Hosmer DW, et

al. Differing risk profiles for individual fracture sites: evidence from the Global

19
 ACCEPTED MANUSCRIPT

Longitudinal Study of Osteoporosis in Women (GLOW). J Bone Miner Res.

2012;27:1907-15.

[26] Oei L, Zillikens MC, Dehghan A, Buitendijk GH, Castaño-Betancourt MC, Estrada

K, et al. High Bone Mineral Density and Fracture Risk in Type 2 Diabetes as Skeletal

PT
Complications of Inadequate Glucose Control: The Rotterdam Study. Diabetes Care.

RI
2013;36:1619-28.

[27] Suzuki K, Katsuno M, Banno H, Takeuchi Y, Atsuta N, Ito M, et al. CAG repeat

SC
size correlates to electrophysiological motor and sensory phenotypes in SBMA. Brain.

2008;131:229-39.

U
[28] Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY, et al.
AN
European guidance for the diagnosis and management of osteoporosis in postmenopausal

women. Osteoporos Int. 2013;24:23-57.

M

[29] Weinstein RS. True strength. J Bone Miner Res. 2000;15:621-5.

D

[30] Chesnut CH, Rosen CJ, Group BQD. Reconsidering the effects of antiresorptive
TE

therapies in reducing osteoporotic fracture. J Bone Miner Res. 2001;16:2163-72.

[31] Seeman E, Delmas PD. Bone quality--the material and structural basis of bone
EP

strength and fragility. N Engl J Med. 2006;354:2250-61.

[32] Nishizawa Y, Ohta H, Miura M, Inaba M, Ichimura S, Shiraki M, et al. Guidelines

C

for the use of bone metabolic markers in the diagnosis and treatment of osteoporosis
AC

(2012 edition). J Bone Miner Metab. 2013;31:1-15.

[33] Garnero P. Biomarkers for osteoporosis management: utility in diagnosis, fracture

risk prediction and therapy monitoring. Mol Diagn Ther. 2008;12:157-70.

[34] Rosen HN, Moses AC, Garber J, Iloputaife ID, Ross DS, Lee SL, et al. Serum CTX:

20
 ACCEPTED MANUSCRIPT

a new marker of bone resorption that shows treatment effect more often than other

markers because of low coefficient of variability and large changes with bisphosphonate

therapy. Calcif Tissue Int. 2000;66:100-3.

[35] Case KO, Brahler CJ, Heiss C. Resting energy expenditures in Asian women

PT
measured by indirect calorimetry are lower than expenditures calculated from prediction

RI
equations. J Am Diet Assoc. 1997;97:1288-92.

[36] Henry CJ. Basal metabolic rate studies in humans: measurement and development of

SC
new equations. Public Health Nutr. 2005;8:1133-52.

[37] Niskanen L, Haffner S, Karhunen LJ, Turpeinen AK, Miettinen H, Uusitupa MI.

U
Serum leptin in relation to resting energy expenditure and fuel metabolism in obese
AN
subjects. Int J Obes Relat Metab Disord. 1997;21:309-13.

[38] Nicklas BJ, Toth MJ, Poehlman ET. Daily energy expenditure is related to plasma
M

leptin concentrations in older African-American women but not men. Diabetes.

D

1997;46:1389-92.
TE

[39] Martin LJ, Jones PJ, Considine RV, Su W, Boyd NF, Caro JF. Serum leptin levels

and energy expenditure in normal weight women. Can J Physiol Pharmacol.

EP

1998;76:237-41.

[40] Turner RT, Kalra SP, Wong CP, Philbrick KA, Lindenmaier LB, Boghossian S, et al.
C

Peripheral leptin regulates bone formation. J Bone Miner Res. 2013;28:22-34.

AC

[41] Kocyigit H, Bal S, Atay A, Koseoglu M, Gurgan A. Plasma leptin values in

postmenopausal women with osteoporosis. Bosn J Basic Med Sci. 2013;13:192-6.

[42] Rezai-Zadeh K, Yu S, Jiang Y, Laque A, Schwartzenburg C, Morrison CD, et al.

Leptin receptor neurons in the dorsomedial hypothalamus are key regulators of energy

21
 ACCEPTED MANUSCRIPT

expenditure and body weight, but not food intake. Mol Metab. 2014;3:681-93.

[43] Shi Y, Yadav VK, Suda N, Liu XS, Guo XE, Myers MG, et al. Dissociation of the

neuronal regulation of bone mass and energy metabolism by leptin in vivo. Proc Natl

Acad Sci U S A. 2008;105:20529-33.

PT
[44] Yadav VK, Oury F, Suda N, Liu ZW, Gao XB, Confavreux C, et al. A serotonin-

RI
dependent mechanism explains the leptin regulation of bone mass, appetite, and energy

expenditure. Cell. 2009;138:976-89.

SC
[45] Yadav VK, Ducy P. Lrp5 and bone formation : A serotonin-dependent pathway. Ann

N Y Acad Sci. 2010;1192:103-9.

U
[46] Oh CM, Namkung J, Go Y, Shong KE, Kim K, Kim H, et al. Regulation of systemic
AN
energy homeostasis by serotonin in adipose tissues. Nat Commun. 2015;6:6794.

[47] Crane JD, Palanivel R, Mottillo EP, Bujak AL, Wang H, Ford RJ, et al. Inhibiting
M

peripheral serotonin synthesis reduces obesity and metabolic dysfunction by promoting

D

brown adipose tissue thermogenesis. Nat Med. 2015;21:166-72.

TE

[48] Iordanidou M, Tavridou A, Petridis I, Arvanitidis KI, Christakidis D, Vargemezis V,

et al. The serotonin transporter promoter polymorphism (5-HTTLPR) is associated with

EP

type 2 diabetes. Clin Chim Acta. 2010;411:167-71.

[49] Nelson PM, Harrod JS, Lamping KG. 5HT(2A) and 5HT(2B) receptors contribute to
C

serotonin-induced vascular dysfunction in diabetes. Exp Diabetes Res. 2012;2012:398406.

AC

[50] Nonogaki K, Strack AM, Dallman MF, Tecott LH. Leptin-independent hyperphagia

and type 2 diabetes in mice with a mutated serotonin 5-HT2C receptor gene. Nat Med.

1998;4:1152-6.

[51] Price JC, Kelley DE, Ryan CM, Meltzer CC, Drevets WC, Mathis CA, et al.

22
 ACCEPTED MANUSCRIPT

Evidence of increased serotonin-1A receptor binding in type 2 diabetes: a positron

emission tomography study. Brain Res. 2002;927:97-103.

[52] Starup-Linde J, Eriksen SA, Lykkeboe S, Handberg A, Vestergaard P. Biochemical

markers of bone turnover in diabetes patients--a meta-analysis, and a methodological

PT
study on the effects of glucose on bone markers. Osteoporos Int. 2014;25:1697-708.

RI
[53] Shu A, Yin MT, Stein E, Cremers S, Dworakowski E, Ives R, et al. Bone structure

and turnover in type 2 diabetes mellitus. Osteoporos Int. 2012;23:635-41.

SC
[54] Terzi R, Dindar S, Terzi H, Demirtaş Ö. Relationships among the metabolic

syndrome, bone mineral density, bone turnover markers, and hyperglycemia. Metab

Syndr Relat Disord. 2015;13:78-83.

U
AN
[55] Al-Daghri NM, Yakout S, Al-Shehri E, Al-Fawaz H, Aljohani N, Al-Saleh Y.

Inflammatory and bone turnover markers in relation to PTH and vitamin D status among
M

Saudi postmenopausal women with and without osteoporosis. Int J Clin Exp Med.
D

2014;7:2812-9.
TE

[56] Vestergaard P, Rejnmark L, Mosekilde L. Are antiresorptive drugs effective against

fractures in patients with diabetes? Calcif Tissue Int. 2011;88:209-14.

EP

[57] Coe LM, Tekalur SA, Shu Y, Baumann MJ, McCabe LR. Bisphosphonate treatment

of type I diabetic mice prevents early bone loss but accentuates suppression of bone
C

formation. J Cell Physiol. 2015.

AC

[58] Barrows K, Snook JT. Effect of a high-protein, very-low-calorie diet on resting

metabolism, thyroid hormones, and energy expenditure of obese middle-aged women.

Am J Clin Nutr. 1987;45:391-8.

[59] Chong PK, Jung RT, Rennie MJ, Scrimgeour CM. Energy expenditure in lean and

23
 ACCEPTED MANUSCRIPT

obese diabetic patients using the doubly labelled water method. Diabet Med.

1993;10:729-35.

[60] Perseghin G. Pathogenesis of obesity and diabetes mellitus: insights provided by

indirect calorimetry in humans. Acta Diabetol. 2001;38:7-21.

PT
[61] DeLany JP, Kelley DE, Hames KC, Jakicic JM, Goodpaster BH. Effect of physical

RI
activity on weight loss, energy expenditure, and energy intake during diet induced weight

loss. Obesity (Silver Spring). 2014;22:363-70.

SC
[62] McNay EC, Teske JA, Kotz CM, Dunn-Meynell A, Levin BE, McCrimmon RJ, et al.

Long-term, intermittent, insulin-induced hypoglycemia produces marked obesity without

U
hyperphagia or insulin resistance: a model for weight gain with intensive insulin therapy.
AN
Am J Physiol Endocrinol Metab. 2013;304:E131-8.

[63] Shi H, Moustaid-Moussa N, Wilkison WO, Zemel MB. Role of the sulfonylurea
M

receptor in regulating human adipocyte metabolism. FASEB J. 1999;13:1833-8.

D

[64] Purnell JQ, Weyer C. Weight effect of current and experimental drugs for diabetes
TE

mellitus: from promotion to alleviation of obesity. Treat Endocrinol. 2003;2:33-47.

[65] Yki-Järvinen H, Ryysy L, Kauppila M, Kujansuu E, Lahti J, Marjanen T, et al.

EP

Effect of obesity on the response to insulin therapy in noninsulin-dependent diabetes

mellitus. J Clin Endocrinol Metab. 1997;82:4037-43.

C

[66] Welle S, Nair KS, Lockwood D. Effect of a sulfonylurea and insulin on energy
AC

expenditure in type II diabetes mellitus. J Clin Endocrinol Metab. 1988;66:593-7.

[67] Furukawa S, Fujita T, Shimabukuro M, Iwaki M, Yamada Y, Nakajima Y, et al.

Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest.

2004;114:1752-61.

24
 ACCEPTED MANUSCRIPT

[68] Liu JJ, Sum CF, Tavintharan S, Yeoh LY, Ng XW, Moh AM, et al. Obesity is a

determinant of arterial stiffness independent of traditional risk factors in Asians with

young-onset type 2 diabetes. Atherosclerosis. 2014;236:286-91.

[69] Fukuda S, Hirata A, Nishizawa H, Nagao H, Kashine S, Kimura T, et al. Systemic

PT
arteriosclerosis and eating behavior in Japanese type 2 diabetic patients with visceral fat

RI
accumulation. Cardiovasc Diabetol. 2015;14:8.

[70] Campos Pastor MM, López-Ibarra PJ, Escobar-Jiménez F, Serrano Pardo MD,

SC
García-Cervigón AG. Intensive insulin therapy and bone mineral density in type 1

diabetes mellitus: a prospective study. Osteoporos Int. 2000;11:455-9.

U
[71] Ten S, Bhangoo A, Ramchandani N, Mueller C, Vogiatzi M, New M, et al. Resting
AN
energy expenditure in insulin resistance falls with decompensation of insulin secretion in

obese children. J Pediatr Endocrinol Metab. 2008;21:359-67.

M

[72] Fagour C, Gonzalez C, Suberville C, Higueret P, Rabemanantsoa C, Beauvieux MC,

D

et al. Early decrease in resting energy expenditure with bedtime insulin therapy. Diabetes
TE

Metab. 2009;35:332-5.

[73] Nakamura K, Oyama M, Saito T, Oshiki R, Kobayashi R, Nishiwaki T, et al.

EP

Nutritional and biochemical parameters associated with 6-year change in bone mineral

density in community-dwelling Japanese women aged 69 years and older: The

C

Muramatsu Study. Nutrition. 2012;28:357-61.

AC

[74] Roux C, Hofbauer LC, Ho PR, Wark JD, Zillikens MC, Fahrleitner-Pammer A, et al.

Denosumab compared with risedronate in postmenopausal women suboptimally adherent

to alendronate therapy: efficacy and safety results from a randomized open-label study.

Bone. 2014;58:48-54.

25
 ACCEPTED MANUSCRIPT

[75] Miyauchi A, Matsumoto T, Sugimoto T, Tsujimoto M, Warner MR, Nakamura T.

Effects of teriparatide on bone mineral density and bone turnover markers in Japanese

subjects with osteoporosis at high risk of fracture in a 24-month clinical study: 12-month,

randomized, placebo-controlled, double-blind and 12-month open-label phases. Bone.

PT
2010;47:493-502.

RI
[76] Strotmeyer ES, Cauley JA, Schwartz AV, de Rekeneire N, Resnick HE, Zmuda JM,

et al. Reduced peripheral nerve function is related to lower hip BMD and calcaneal QUS

SC
in older white and black adults: the Health, Aging, and Body Composition Study. J Bone

Miner Res. 2006;21:1803-10.

U
[77] Fukuda T, Takeda S, Xu R, Ochi H, Sunamura S, Sato T, et al. Sema3A regulates
AN
bone-mass accrual through sensory innervations. Nature. 2013;497:490-3.

[78] Kim JH, Jung MH, Lee JM, Son HS, Cha BY, Chang SA. Diabetic peripheral
M

neuropathy is highly associated with nontraumatic fractures in Korean patients with type
D

2 diabetes mellitus. Clin Endocrinol (Oxf). 2012;77:51-5.

TE

[79] Rasul S, Ilhan A, Wagner L, Luger A, Kautzky-Willer A. Diabetic polyneuropathy

relates to bone metabolism and markers of bone turnover in elderly patients with type 2
EP

diabetes: greater effects in male patients. Gend Med. 2012;9:187-96.

[80] Kimura A. Examination of motor and sensory neuron in normal subjects and patients
C

with Vibration Syndrome. Report of the Council in Japanese Ministry of Health, Labour
AC

and Welfare,. 2002.

[81] Suzuki A, Kotake M, Ono Y, Kato T, Oda N, Hayakawa N, et al. Hypovitaminosis

D in type 2 diabetes mellitus: Association with microvascular complications and type of

treatment. Endocr J. 2006;53:503-10.

26
 ACCEPTED MANUSCRIPT

[82] Westerterp KR. Food quotient, respiratory quotient, and energy balance. Am J Clin

Nutr. 1993;57:759S-64S; discussion 64S-65S.

[83] Garby L, Astrup A. The relationship between the respiratory quotient and the energy

equivalent of oxygen during simultaneous glucose and lipid oxidation and lipogenesis.

PT
Acta Physiol Scand. 1987;129:443-4.

RI
[84] Jorde R, Figenschau Y, Hutchinson M, Emaus N, Grimnes G. High serum 25-

hydroxyvitamin D concentrations are associated with a favorable serum lipid profile. Eur

SC
J Clin Nutr. 2010;64:1457-64.

[85] Cutillas-Marco E, Prosper AF, Grant WB, Morales-Suárez-Varela MM. Vitamin D

U
status and hypercholesterolemia in Spanish general population. Dermatoendocrinol.
AN
2013;5:358-62.

[86] Kayaniyil S, Vieth R, Retnakaran R, Knight JA, Qi Y, Gerstein HC, et al.

M

Association of vitamin D with insulin resistance and beta-cell dysfunction in subjects at

D

risk for type 2 diabetes. Diabetes Care. 2010;33:1379-81.

TE

[87] Kayaniyil S, Vieth R, Harris SB, Retnakaran R, Knight JA, Gerstein HC, et al.

Association of 25(OH)D and PTH with metabolic syndrome and its traditional and
EP

nontraditional components. J Clin Endocrinol Metab. 2011;96:168-75.

C
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Figure Legend

Fig. 1. Correlation diagram of the relationship between basal metabolism and bone

metabolism.

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A: Correlation between serum carboxy-terminal collagen crosslinks-1 (CTX-1) levels

and mean glycated hemoglobin (HbA1c) levels for the previous 6 months (y = –0.05x +

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0.71: r2 = 0.140). B: Correlation between resting energy expenditure (REE) and the

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procollagen type 1 N-terminal propeptide (P1NP) to CTX-1 ratio (y = 0.08x + 35.58: r2

= 0.144). C: Correlation between serum vitamin D levels and respiratory quotient (y =

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30.18x + 5.06: r2 = 0.150).
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Table 1. Patient characteristics (n = 46)

Age 65.0 ± 5.9 Ca (mg/dL) 9.2 ± 0.3

BMI 24.5 ± 3.6 P (mg/dL) 3.6 ± 0.4
Tobacco (+/-) 5 / 41 25OHD (ng/mL) 21.8 ± 7.7
Alcohol (+/-) 11 / 35 iPTH (pg/mL) 59.5 ± 17.5

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Serum fasting blood sugar Serum CTX-1
(mmol/L) 8.3 ± 2.7 (ng/mL) [normal] 0.36 ± 0.13 [0.56 ± 0.23]*
HbA1c (%) 7.5 ± 1.1

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Serum P1NP 37.6 ± 11.7 [45.1
Mean HbA1c prior for 6 7.6 ± 1.1 (ng/mL) [normal] (20.3–76.3)]**
months (%) BMD (g/cm2) 0.472 ± 0.0730

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Family history of bone
fracture (+/-) 15 / 31 T-score –1.76 ± 1.52
Past history of bone

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fracture Respiratory
(atraumatic/traumatic/none) 9 / 1 / 36 quotient 0.88 ± 0.098
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Duration of diabetes 15.8 ± 8.7
REE / estimated
Insulin/OHA/diet 13/30/3 940.5 ± 155.7 / 1,176.7 ±
normal average
SU/thiazolidine/ 98.3
(Cal)
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DPPIV-I/biguanide 21/1/14/16
Antihypertensive drug (+/-) 24 / 22
Lipid lowering agent
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(statins) 30 (24) / 16
MCV ulnar/
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Retinopathy (P/S/N) 7 / 10 / 29 peroneal 55.0 ± 4.5 / 46.3 ± 5.0

Urine albumin (+/-) 7 / 39 SCV ulnar/sural 51.5 ± 3.7 / 48.9 ± 7.7
Creatinine (mg/dL) 0.67 ± 0.15 R-R interval (s) 115 ± 5.9
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HDL (mg/dL) 64.8 ± 16.9 Resting (upright)

systolic BP
Triglyceride (mg/dL) 131.7 ± 101.0 (mmHg) 136.3 ± 17.8 (139.0 ± 22.3)
LDL (mg/dL) 123.2 ± 30.2 Resting (upright)
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diastolic BP
CPR (ng/mL) 1.6 ± 0.7 (mmHg) 74.6 ± 9.6 (78.4 ± 10.5)
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Blood pressure values in parentheses indicate the pressure in the upright position. Data

for non-diabetic subjects are shown in brackets. *Mean ± standard deviation in normal

postmenopausal women. **Mean (5th–95th percentile) in normal postmenopausal

women without hormone replacement therapy. BMI: body mass index, Hb1Ac: glycated

hemoglobin, OHA: oral hypoglycemic agent, SU: sulfonylurea, DPPIV-I:

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dipeptidyl-peptidase IV inhibitor, HDL: high-density lipoprotein, LDL: low-density

lipoprotein, CPR: C-peptide response, Ca: calcium, P: phosphate, 25OHD:

25-hydroxyvitamin D, iPTH: intact parathyroid hormone, CTX-1: carboxy-terminal

collagen crosslinks-1, P1NP: procollagen type 1 N-terminal propeptide, BMD: bone

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mass density, REE: resting energy expenditure, MCV: motor nerve velocity, SCV:

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sensory nerve velocity, BP: blood pressure.

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Table 2. Characteristics of patients with low and normal levels of vitamin D

Characteristics Patients with 25OHD Patients with 25OHD

≤20 ng/mL, n = 23 >20 ng/mL, n = 23
Age 64.9 ± 4.9 65.1 ± 6.9

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BMI 24.7 ± 4.1 24.3 ± 3.0
Percent body fat 34.9 ± 6.0 34.2 ± 5.5
Lean body mass (kg) 37.1 ± 3.0 37.3 ± 3.2

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REE (Cal) 948.4 ± 144.7 932.7 ± 168.9
Fasting blood glucose

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(mmol/L) 8.1 ± 2.9 8.4 ± 2.5
HbA1c (%) 7.6 ± 1.3 7.7 ± 1.0
Average HbA1c over the
previous 6 months (%) 7.5 ± 1.2 7.7 ± 1.0

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Serum creatinine (mg/dL) 0.66 ± 0.1 0.66 ± 0.1
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HDL (mg/dL) 65.4 ± 17.4 62.2 ± 16.3
Triglyceride (mg/dL) 144.6 ± 130.5 124.3 ± 56.9
LDL (mg/dL) 122.8 ± 29.8 123.2 ± 31.7
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Ca (mg/dL) 9.2 ± 0.3 9.2 ± 0.4

P (mg/dL) 3.6 ± 0.3 3.6 ± 0.4
CPR (ng/mL) 1.39 ± 0.6* 1.98 ± 0.6*
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CTX-1 (ng/mL) 0.33 ± 0.11 0.40 ±0.14

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PINP 33.3 ± 7.3 41.8 ± 13.7

BMD total 0.474 ± 0.08 0.471 ± 0.06
Habit of exercising >30 min
twice per week 9* 17 *
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*p < 0.05.
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BMI: body mass index, REE: resting energy expenditure, Hb1Ac: glycated hemoglobin,
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HDL: high-density lipoprotein, LDL: low-density lipoprotein, Ca: calcium, P:

phosphate, CPR:C peptide, CTX-1: carboxy-terminal collagen crosslinks-1, P1NP:
procollagen type 1 N-terminal propeptide, BMD: bone mass density, 25OHD:
25-hydroxyvitamin D.

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Table 3. The results of the regression analysis for basal metabolism and bone
metabolism, which was performed for each pair that exhibited a significant correlation.
CTX-1 P1NP P1NP/CTX-1 ratio BMD

β p R2 β p R2 β p R2 β p R2

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Age 0.15 0.34 0.00 –0.03 0.82 –0.02 –0.22 0.15 0.03 –0.43 0.00* 0.16

BMI –0.26 0.08 0.05 0.02 0.89 –0.02 0.46 0.00* 0.19 0.34 0.021* 0.10

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Fat mass –0.30 0.04* 0.07 –0.01 0.96 –0.02 0.47 0.00* 0.20 0.33 0.027* 0.09

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% fat mass –0.22 0.14 0.03 0.00 1.00 –0.02 0.38 0.01* 0.12 0.25 0.10 0.04

REE –0.18 0.22 0.01 0.07 0.64 –0.02 0.38 0.01* 0.13 0.24 0.11 0.04

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RER –0.10 0.53 –0.01 0.20 0.18 0.02 0.34 0.02* 0.09 0.04 0.78 –0.02
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Albumin 0.21 0.16 0.02 0.12 0.44 –0.01 –0.17 0.25 0.01 –0.33 0.02* 0.09

ALP 0.10 0.53 –0.01 0.37 0.01* 0.12 0.42 0.00* 0.16 0.33 0.02* 0.09
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HbA1c –0.40 0.01* 0.14 –0.41 0.01* 0.15 0.19 0.20 0.02 0.23 0.13 0.03
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Mean HbA1c –0.39 0.01* 0.13 -0.27 0.07 0.05 0.26 0.08 0.05 0.24 0.12 0.03
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iPTH 0.17 0.26 0.01 –0.17 0.25 0.01 –0.33 0.03* 0.09 0.10 0.52 –0.01

25OHD 0.18 0.22 0.01 0.32 0.03 0.08 0.05 0.76 –0.02 –0.18 0.22 0.01
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BMI: body mass index, REE: resting energy expenditure, RER: resting exchange ratio,
ALP: alkaline phosphatase, Hb1Ac: glycated hemoglobin, iPTH: intact parathyroid
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hormone, 25OHD: 25-hydroxyvitamin D. All coefficients for determination data were

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adjusted (r2).

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Table 4. Independent effect of objectively measured mean HbA1c levels during the

previous 6 months on CTX-1 and P1NP, and the effect of resting energy expenditure on

the P1NP/CTX-1 ratio.

CTX-1 P1NP P1NP/CTX-1 ratio BMD

PT
β p R2 β p R2 β p R2 β p R2

RI
Model 1

Mean HbA1c –0.37 0.02* 0.11 –0.35 0.03* 0.07 0.13 0.40 0.12 0.17 0.30 0.04

SC
REE –0.04 0.81 0.21 0.19 0.33 0.04* 0.17 0.29

Model 2
U
AN
Age 0.00 0.98 0.09 –0.13 0.40 0.06 –0.10 0.53 0.11 –0.38 0.02* 0.14
M

Mean HbA1c –0.37 0.03* –0.39 0.02* 0.10 0.53 0.05 0.78

REE –0.24 0.81 0.19 0.23 0.32 0.05* 0.12 0.43

D
TE

All models included 46 participants.

Hb1Ac: glycated hemoglobin, REE: resting energy expenditure, CTX-1:
carboxy-terminal collagen crosslinks-1, P1NP: procollagen type 1 N-terminal
EP

propeptide, BMD: bone mass density.

C
AC

5
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A 0.8

Serum CTX-1 level (mg/dl)

0.6

0.4

PT
0.2

RI
6.0 8.0 10.0 12.0
Mean HbA1c : 6months (%)

SC
250
B
P1NP/CTX-1 ratio

U
200
AN
150
M

100
D

50
TE

400 600 800 1000 1200 1400

Resting energy expenditure (Cal)
EP

50
Serum 25(OH)D (ng/ml)

C
C

40
AC

30

20

10

0
0.7 0.8 0.9 1.0 1.1 1.2
Respiratory quotient
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Highlights

Basal metabolic rate and bone metabolism were evaluated in postmenoposal

patients with type 2 diabetes

Bone metabolism was associated with resting energy expenditure (REE).

PT

Serum vitamin D was associated with respiratory quotient (RQ) and insulin

RI
requirement.

U SC
AN
M
D
TE
C EP
AC