MINISTRY OF EDUCATION
MINISTRY OF DEFENSE
AND TRAINING
VIETNAM MILITARY MEDICAL UNIVERSITY

NGO DUC KY

REREARCH OF OSTEOCALCIN CONCENTRATION,
BODY COMPOSITION, BONE MINERAL DENSITY
IN TYP E 2 DIABETES MELLITUS

Specialized : Internal Medical
Code

: 9720107

DOCTORAL THESIS

HANOI - 2019


THE WORK WAS COMPLETED AT
VIETNAM MILITARY MEDICAL UNIVERSITY

Science instructor:
1. Assoc.Prof. Doan Van De
2. Assoc.Prof. Dang Hong Hoa
Reviewer 1:Assoc.Prof. Ta Van Binh

Reviewer 2:Assoc.Prof. Nguyen Khoa Dieu Van


exhibits changes in body composition, which is to increase fat mass,
reduce lean mass and reduce minerals. Abdominal fat mass (or body fat)
and total fat intake are strongly related to insulin resistance, development
of type 2 diabetes and blood glucose control in patients with type 2
diabetes has been demonstrated.
Osteocalcin is a bone marrow imprint associated with bone
resorption. Recently, it has been found that interactions between bone
metabolism and glucose metabolism are related through osteocalcin
activity both in vivo and in vitro ..
The role of osteocalcin, lean mass and lean body mass in glucose
metabolism and insulin resistance has been mentioned by studies. But
there is little data on special clinical research in Vietnam. DEXA
measurements are considered an optimal method to evaluate body
composition.
Therefore, we carried out the research: "Research of osteocalcin
concentration, body composition, bone mineral density in type 2 diabetic
patients" with 2 focus:
1. Assessment of serum osteocalcin concentration, body
composition, bone density in patients with type 2 diabetes mellitus
2. Analysis of the relationship between serum osteocalcin, changes
in body composition, bone mineral density with characteristics of type 2
diabetic patients.
CHAPTER 1: OVERVIEW
1.1. Risk factors and insulin resistance in type 2 diabetes
1.1.1. Risk factors:
Risk factors for type 2 diabetes are classified into four major risk
groups, such as genetics, anthropology, lifestyle behaviors and
transitional risk groups (intermediate risk).



Many studies have found high rates of diabetes in people with the
most saturated, high-carbohydrate diets. In addition, deficiency of trace
elements or vitamins contributes to the progression of disease in young
people as well as the elderly.
+ Other factors
Different studies around the world show that diabetes is growing
rapidly in developing countries, with rapid urbanization; these are places
where there is a transition in nutrition, lifestyle, stress, ...


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* Metabolic factors and types of intermediate risks
Reducing fasting glucose tolerance, reducing glucose tolerance.
Factors related to pregnancy (birth status, gestational diabetes, diabetes,
descendants of diabetic women during pregnancy, intrauterine
environment).
In general, type 2 diabetes is a consequence of the complex
interaction between genetic factors and lifestyle factors. Risk factors for
type 2 diabetes include unchangeable factors and modifiable factors.
1.1.2 Fat tissue and insulin resistance in type 2 diabetes
1.1.2.1. Fat and insulin resistance
Insulin resistance is considered to be an inherently unrelated
component of the disease in most patients. Obesity is often associated
with insulin resistance, because most type 2 diabetes is obese. Insulin
resistance due to obesity is considered a contributing factor in insulin
diseases and sensitivity.
As we know, obesity is a risk factor for the development of type 2
diabetes and cardiovascular disease. However, it is now recognized that a
small proportion of individuals have reduced cardiovascular risk despite
being obese. Studies have revealed the molecular and metabolic

of the microbial environment of the bone being recovered, then the
interaction with pancreatic β cells to release Insulin affects energy
metabolism. The molecular mechanism of undercarboxylated (ucOC)
with the interaction between osteocalcin and β cells of the pancreas is
unclear. On the other hand, leptin derived from adipose tissue cells may
act as a signal inhibiting the activity of osteocalcin in the feed transition
loop of insulin activity. Thus, on the bone-pancreas axis can affect energy
metabolism. Insulin interacts with osteoblast through an insulin receptor
(IR) to produce osteocalcin. Carboxylated osteocalcin turns into
undercarboxylated osteocalcin (ucOc) as an active form.


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Figure 1.7. Relationship between bone and pancreas
+ Associated with fat metabolism
On osteoblast cells, there is a receptor of adiponectin and when
adiponectin binds to the specific receptor stimulates osteocalcin
expression in osteoblasts. Adiponectin stimulates the expression of
osteocalcin and osteoblasts cells through the activation pathway of active
kinase protein AMPK (AMPK).

Figure 1.8. Relationship between bone - pancreas and adipose tissue


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1.3. Changes in body composition and bone mineral
density in type 2 diabetes
1.3.1. Body composition change in type 2 diabetes:
Lean mass: this is the main body component, determining the basic

+ Advantages: Can accurately calculate each component of fat mass,
lean mass, mineral block in each part, low beam dose.
+ Disadvantages: high cost, only in big centers.
1.3.5. The problems still exist
Studies in the world have mentioned bone density, osteoporosis, lean
mass and fat content in type 2 diabetic patients, especially serum
osteocalcin levels were also studied and published. The problem of
studying bone density, the rate of osteoporosis in Vietnam has also been
mentioned by many studies, however, the rate of lean mass, fat mass and
mineral mass of bone has not yet been mentioned in diabetic patients.
The type of osteocalcin has not yet been studied in a type 2 diabetic
patient, even studies of normal human concentration are not available.
Therefore, the study of serum osteocalcin concentration, body
composition, and bone density in type 2 diabetic patients is still
necessary in Vietnam.
CHAPTER 2: SUBJECTS AND METHODS OF RESEARCH
2.1. Research subjects
The study carried out over 218 subjects divided into 2 groups:
- Diseases: 151 patients were diagnosed with type 2 diabetes, were
treated and monitored at Nghe An General Friendship Hospital.


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- Control group: 67 people who do not have diabetes similar to age
and gender selected as control group.
- Time from 07/2015 - 12/2017.
2.1.1. Standard for control group selection
- Being normal people who are similar in gender and age compared
to disease groups
- Do not have diabetes, starvation blood glucose is bright
2.2. Research Methods


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2.2.1. Research design: Prospective study, cross-sectional description,
compared with control group without type 2 diabetes. Apply convenient
sample size without probability.
2.2.2. Steps to conduct research: All patients are conducted through the
following steps:
2.2.2.1. Clinical examination: All patients participating in the study
were asked about diseases, exploited history, clinical examination
according to a uniform medical record.
BMI (Body mass index): body mass index
BMI = Weight (kg) / {Height (m)} 2
2.2.2.2. Making laboratory tests:
Laboratory tests are performed at the Biochemistry Department Nghe An General Friendship Hospital.
Blood tests:
- Taking venous blood in the morning (fasting), centrifuging plasma.
- Quantify lipid components TG, TC, LDL-C, HDL-C in plasma,
blood glucose, urea, creatinine, GOT, GPT at Biochemistry Department Nghe An General Friendship Hospital , by system Rocho's COBAS 6000
and COBAS e 601 automatic
- HbA1c test: by turbidity measurement method.
- Testing of insulin and C-peptid: by electro-chemiluminescence
immunoassay.
- Serum osteocalcin test: quantify osteocalcin concentration in
Department of Pathophysiology - Military Medical Academy. Kit uses
ELISA principle to determine ostecalcin concentration in plasma.
Measure bone mineral density, body composition by DEXA method.
Performed in Functional Science Department, Nghe An General
Friendship Hospital. Type: Hologic Explorer of American.

Pearson correlation, if the variable does not follow the law of normal
distribution, then check the non-Spearman parameter. The correlation
coefficient r is from - 1 to + 1. When r> 0: homologous correlation, r
considered in conjunction with BMD measurements.
4.3. Association between serum osteocalcin, body mass composition,
bone mineral density with some characteristics of type 2 diabetes
4.3.1. Relationship between osteocalcin concentration and some
patient characteristics
4.3.1.1. Relationship between osteocalcin concentration and HbA1c,
HMOA2-IR
Osteocalcin has been shown to prevent hyperglycemia and reduce
the risk of type 2 diabetes in in vivo as well as in mice. In clinical
practice in type 2 diabetic patients, there are many studies in different
subjects or races in the world that have proved this. Thus, serum
osteocalcin levels are inversely correlated with HbA1c index in type 2
diabetic patients and also as a marker suggesting an association between
diabetes and osteoporosis.
Osteocalcin in the active form acts on the pancreas to increase
insulin secretion, increase pancreatic beta cell mass and reduce insulin
resistance in peripheral tissues. From our results as well as other studies
we find that osteocalcin secreted from osteoblast cells acts on glucose
metabolism by increasing pancreatic insulin secretion and reducing
insulin resistance.
The results of multivariate linear regression analysis show that
osteocalcin is an independent factor associated with type 2 diabetes.


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Osteocalcin is also statistically independently correlated with HbA1c and
HOMA2-IR insulin resistance.
4.3.2. Relationship between body composition and characteristics of
type 2 diabetes
The percentage of fat exerted on the control of blood glucose rather



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reducing HbA1C levels is a target standard of diabetes care that has been
shown to reduce microvascular complications. It can be affirmed that
good blood glucose control can have a positive effect on bone health.
Good control of blood glucose is to increase bone density, increase bone
quality, thereby reducing the risk of osteoporosis / fracture in patients,
even if excessive control of the blood is likely to result in hypoglycemic
episodes. resulting in cracks or fractures due to falls.
4.3.3.4. The relation between BMD and fat mass, lean mass
Adipose tissue is considered an endocrine organ, which is secreted
by adipokin cells as cytokines as mediators of bone metabolism. Leptin
and adiponectin affect bone formation and bone restoration and are
considered as bone metabolism regulators. When assessing lean mass and
fat mass separately, lean mass was determined to play the most important
role in determining bone mass during bone transfer. Lean mass is an
independent independent factor that increases bone density and bone
mass. In type 2 diabetic patients, muscle mass will decrease and muscle
activity will be reduced. On the other hand, a reduction in lean mass
increases insulin resistance, which may have a direct effect on bone
quality in type 2 diabetes.

CONCLUSION
1. Variation in serum osteocalcin concentration and association in 1.
Characteristics of serum osteocalcin concentration, body mass
composition, bone mineral density in type 2 diabetic patients
- Serum osteocalcin concentration in patients with type 2 diabetes is
lower than the control group without diabetes with statistical significance
(p