Effect of a Symptom–Psychology–Society Three-Dimensional Intervention on Fracture Prevention and Metabolic Control in Diabetes with Osteoporosis

Summary

This retrospective clinical study evaluated a symptom-psychology-society three-dimensional nursing intervention integrating symptom management, psychological counseling, and hospital-family-community support for patients with diabetes complicated by osteoporosis.

Abstract

Diabetes mellitus complicated with osteoporosis requires coordinated management of metabolic control, bone health, psychological status, and social support. This retrospective clinical study evaluated a symptom-psychology-society three-dimensional nursing intervention for patients with diabetes complicated by osteoporosis. A retrospective evaluation was conducted in 132 patients with diabetes complicated by osteoporosis. Patients were categorized according to the nursing pathway documented in medical and nursing records: routine nursing or a three-dimensional intervention. The intervention consisted of three sequential components. First, symptom management included individualized glucose monitoring, medication-adherence support, dietary and exercise guidance, calcium and vitamin D supplementation guidance, and osteoporosis-related follow-up. Second, psychological support included SAS/SDS-based screening, monthly counseling for patients exceeding predefined thresholds, routine emotional support for patients below the thresholds, and referral when persistent severe symptoms were identified. Third, social support included family education, community-health linkage, monthly home visits, and adherence documentation. Outcomes were assessed at baseline, 6 months, and 12 months, including BMD, FRAX scores, metabolic indicators, SAS, SDS, SSRS, and fracture occurrence. The intervention group showed more favorable changes in BMD, FRAX scores, metabolic indicators, psychological scores, social support, and total 12-month fracture incidence than the routine nursing group. These findings provide preliminary clinical evidence for a structured and reproducible nursing pathway for integrated management of diabetes complicated by osteoporosis.

Introduction

Osteoporosis (OP) is an insidious and slowly progressive skeletal disorder and an important contributor to fracture-related disability in patients with diabetes mellitus (DM)¹. Beyond its skeletal consequences, OP imposes a substantial burden across multiple health sectors, including emergency care, orthopedic surgery, rehabilitation, long-term nursing, primary care, and public health services. Osteoporotic and fragility fractures are associated with hospitalization, surgical treatment, loss of mobility, prolonged rehabilitation, reduced quality of life, and increased care dependency. Recent population-based and modeling studies further indicate that hip fracture trends are influenced not only by anti-osteoporotic treatment but also by population-level risk factors, physical activity, body mass index, diabetes prevalence, fall-related medication exposure, and the availability of preventive public health strategies^2,3. These findings suggest that fracture prevention requires coordinated management across clinical care, rehabilitation, community health, and health policy sectors rather than pharmacological treatment alone. Clinical evidence indicates that the incidence of OP in patients with DM is 30% to 50% higher than that in healthy individuals, accompanied by a substantially increased risk of fractures^4,5. Meanwhile, patients with DM complicated with OP often present with metabolic disturbances such as blood glucose fluctuations and dyslipidemia, which in turn further aggravate bone metabolism imbalance, forming a vicious cycle⁶. Additionally, long-term illness tends to induce negative emotions (e.g., anxiety and depression) in patients, and insufficient social support may compromise intervention adherence, thereby reducing the efficacy of clinical management⁷. Therefore, interventions for such patients need to take into account multiple dimensional factors.

Currently, clinical interventions for patients with DM complicated with OP mainly focus on hypoglycemic medications, calcium supplementation, and anti-osteoporotic therapy. Although these measures can control blood glucose and improve bone mineral density (BMD) to a certain extent, they lack attention to the targeted relief of physical symptoms, regulation of psychological status, and establishment of social support systems⁸. Despite these limitations, integrated care models for chronic diseases emphasize continuous education, individualized lifestyle management, psychological support, and family or community participation. Integrated care models for chronic diseases emphasize continuous education, individualized lifestyle management, psychological support, and family or community participation. However, in patients with DM complicated with OP, evidence remains limited regarding models that simultaneously target physical symptoms, psychological status, and social-support resources. Most existing studies have explored the effects of single-dimensional interventions, lacking systematic investigations into the synergistic effects of symptom improvement-psychological counseling-social support. Furthermore, the long-term efficacy of multi-dimensional interventions in fracture risk prevention and the underlying mechanisms of metabolic disorder amelioration remain unclear⁹. Previous studies have commonly focused on isolated intervention components, such as exercise rehabilitation, dietary management, or pharmacological treatment, and have differed in study design, intervention duration, and sample size¹⁰. Such heterogeneity makes it difficult to determine whether an integrated model combining symptom management, psychological counseling, and social support provides additional clinical benefit. A retrospective design was used because the three-dimensional care pathway had already been implemented in routine clinical nursing practice, allowing evaluation of real-world 12-month records. Nevertheless, this design cannot eliminate selection bias or unmeasured confounding, and these limitations were considered when interpreting the findings.

Based on the aforementioned research gaps, this study developed and evaluated a symptom-psychology-society three-dimensional intervention model in patients with DM complicated with OP. Rather than proposing each intervention component as entirely new, this study aimed to assess the clinical value of integrating symptom management, psychological counseling, and hospital-family-community support within a single structured nursing pathway. This model may be most applicable to endocrinology departments, osteoporosis clinics, rehabilitation units, and community-linked chronic disease management programs where patients require continuous monitoring, psychological support, and family or community participation. The hypothesis was that, compared with routine nursing, the symptom-psychology-society three-dimensional intervention would be associated with greater improvement in L1–4 BMD and more favorable metabolic, psychological, social-support, and fracture-related outcomes over 12 months.

Protocol

This study was approved by the Medical Ethics Committee of our hospital, and all patients signed informed consent forms. Because this was a retrospective review of clinical records, consent for the nursing intervention was obtained as part of routine care, and written informed consent for the use of anonymized clinical data for research purposes was obtained before data extraction.

Study Subjects

Clinical data from 132 patients with DM complicated by OP admitted to our hospital from March 2023 to December 2024 were retrospectively collected. The study period referred to the time when eligible patients initiated the recorded nursing pathway. The final analysis included only patients with complete baseline, 6-month, and 12-month follow-up records; patients who had not completed 12 months of follow-up by the time of data extraction were excluded during screening. Eligible patients met the diagnostic criteria for DM,¹¹ met the diagnostic criteria for OP, defined as an L1–4 or femoral neck BMD T-score of ≤ -2.5,¹² , had complete clinical data including intervention records, follow-up data, and relevant examination results, and were aged 40 years or older. Patients were excluded if they had severe dysfunction of major organs such as the heart, liver, or kidney; malignant tumors, hyperthyroidism, or other diseases affecting bone metabolism; mental illness or cognitive impairment preventing cooperation with interventions and follow-up; loss to follow-up or interruption of intervention due to other reasons during the follow-up period; or a history of fracture or anti-osteoporotic surgery within the past 6 months. Grouping was based on the predefined nursing pathway documented in the medical and nursing records, rather than randomization. Patients managed with routine nursing were included in the control group, whereas those managed with the symptom-psychology-society three-dimensional nursing pathway were included in the observation group. No propensity-score matching was performed because of the limited sample size. To reduce confounding, baseline characteristics were compared between groups, and sensitivity analyses were conducted with adjustment for age, sex, BMI, duration of DM, and baseline BMD.

Sample Size Calculation

The 12-month change in L1–4 BMD was used as the primary outcome measure for sample size estimation, the sample size calculation was performed using a statistical software. The assumed effect sizes were based on previously published intervention data in patients with type 2 diabetic osteoporosis and our preliminary clinical audit: the expected 12-month change in L1–4 BMD was 0.02 ± 0.08 g/cm² in the routine nursing group and 0.08 ± 0.07 g/cm² in the three-dimensional intervention group. Setting α = 0.05 (two-tailed) and β = 0.20 (statistical power = 80%), the minimum required sample size was calculated to be 132 cases, which was consistent with the sample size enrolled in this study.

Intervention Measures

The follow-up period for both groups of patients was 12 months.

Control group: routine nursing

Patients in the control group received routine nursing, including basic health education, routine medication guidance, basic dietary and exercise recommendations, and routine follow-up. Basic health education consisted of one group health lecture upon admission and another before discharge to explain knowledge about DM and OP, as well as medication precautions. Routine medication guidance informed patients of the method of taking treatment drugs, dosage, and common adverse reactions. Basic dietary and exercise recommendations were provided through dietary and exercise guidance manuals, and patients were advised to follow a low-sugar and low-fat diet and engage in moderate physical activities such as walking. Routine follow-up was conducted by telephone once every 3 months after discharge to assess medication adherence and remind patients of regular re-examinations.

Observation group: Symptom-Psychology-Society Three-Dimensional Intervention

On the basis of routine nursing, patients in the observation group received targeted symptom intervention, personalized psychological counseling, and hospital-family-community collaborative social support. Targeted symptom intervention involved individualized plans based on patients' specific symptoms. For blood glucose management, blood glucose levels were dynamically monitored, hypoglycemic drug dosages were adjusted by attending endocrinologists according to standardized treatment protocols and current clinical guidelines, and personalized dietary and exercise interventions were implemented with targets of FPG 4.4–7.0 mmol/L and HbA1c < 7.0%. Nursing staff were responsible for education, adherence support, follow-up documentation, and communication of abnormal findings to physicians. Baseline and follow-up use of hypoglycemic agents, calcium/vitamin D, bisphosphonates, and other anti-osteoporotic medications was extracted from medical records and compared between groups. For bone metabolism regulation, calcium supplementation at 1000 mg/d plus vitamin D at 800 IU/d was standardized, and anti-osteoporotic drugs, such as bisphosphonates, were adjusted according to BMD results.

Personalized psychological counseling was delivered by trained endocrinology nurses who had received standardized training in chronic disease psychological support and health education. Psychological status was assessed using the SAS and SDS before intervention. Patients with anxiety or depression, defined as SAS score > 50 or SDS score > 53, received personalized psychological counseling once a month for 30–60 min each session, including emotional catharsis guidance, disease-related cognitive education, and positive attitude cultivation. Patients with SAS ≤ 50 and SDS ≤ 53 received routine psychological education and emotional support during follow-up; structured monthly counseling was initiated only if subsequent assessments exceeded the predefined thresholds. Therefore, patients who met the SAS or SDS threshold throughout follow-up could receive up to 12 individualized counseling sessions over the 12-month period. When patients showed severe or persistent anxiety or depressive symptoms, referral to a psychiatrist or clinical psychologist was recommended according to routine hospital practice.

Hospital-family-community collaborative social support was established through linkage with patients' families and community health service centers. Families were educated about disease care and were guided to provide emotional support and daily living assistance. Community medical staff conducted monthly home visits to supervise implementation of intervention plans and promptly address problems encountered during home care. Completion of each scheduled home visit was recorded in the community follow-up form. Home-visit adherence was calculated as the number of completed visits divided by the number of scheduled visits, and adherence of ≥80% was considered acceptable. FRAX scores were calculated using the China-specific model of the web-based FRAX tool, with femoral neck BMD included. The 10-year probabilities of major osteoporotic fracture and hip fracture were recorded for analysis.

Observation Indicators and Follow-Up

The follow-up period was 12 months and combined outpatient visits with telephone follow-up. Outpatient follow-up was conducted at baseline, 6 months, and 12 months after intervention to complete indicator detection and scale assessment. Telephone follow-up was performed once a month during the follow-up period to record intervention adherence, symptom changes, and adverse events. All observation indicators were measured at the three aforementioned outpatient follow-up time points. Lumbar spine L1–4 and left femoral neck BMD were measured using dual-energy X-ray absorptiometry.

Five milliliters of early morning antecubital venous blood were collected, and serum was separated by centrifugation for laboratory testing. FPG was measured by the glucose oxidase method using an automated biochemical analyzer. HbA1c was measured by high-performance liquid chromatography using an automated glycosylated hemoglobin analyzer. TC, TG, LDL-C, and HDL-C were measured by enzymatic methods using an automated biochemical analyzer.

The SAS¹³ consists of 20 items with a 4-point scoring system, with a total score ranging from 20 to 80; higher scores indicate more severe anxiety, with a cut-off value of 50. The SDS¹³ includes 20 items with a 4-point scoring system, with a total score of 20 to 80; higher scores indicate more severe depression, with a cut-off value of 53. The Social Support Rating Scale (SSRS)¹⁴ comprises 10 items with a total score of 12 to 66; higher scores indicate higher levels of social support.

Statistical Analysis

Data were analyzed using statistical software. Continuous variables were tested for normality using the Shapiro-Wilk test and were expressed as mean ± standard deviation or median (interquartile range), as appropriate. Between-group comparisons were performed using the independent-samples t test or Mann-Whitney U test, and within-group changes over time were analyzed using repeated-measures analysis of variance or an appropriate non-parametric method. When multiple pairwise comparisons were performed, Bonferroni correction was applied. Count data were presented as n (%) and compared using the χ² test or Fisher's exact test, as appropriate. Sensitivity analyses were performed with adjustment for age, sex, BMI, duration of DM, and baseline BMD where applicable. Correlation analysis was performed using Pearson's correlation analysis and was interpreted as exploratory. A two-sided P<0.05 was considered statistically significant. Because the present analysis included only patients with complete baseline, 6-month, and 12-month records, complete-case analysis was used and no imputation was performed.

Results

Comparison of Baseline Clinical Data

Intergroup comparison showed no statistically significant differences between the two groups in gender composition, age distribution, duration of DM, time of OP diagnosis, BMI level, smoking and drinking history, or the incidence of comorbidities (e.g., hypertension) (P>0.05). Representative baseline variables were comparable between the control and observation groups, including age (62.90 ± 8.21 vs. 63.89 ± 8.52 years, P = 0.50...

Discussion

This study constructed a targeted symptom intervention-personalized psychological counseling-social support linkage three-dimensional intervention model. Compared with routine nursing, this model was associated with more favorable BMD, fracture-related, metabolic, psychological, and social-support outcomes in patients with DM complicated with OP.

After 6 months of intervention, the observation group showed a significant increase in L1–4 and femoral neck BMD and a significant decrease in ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Automated biochemical analyzer	Beckman Coulter (United States)	AU5821	Measurement of fasting plasma glucose (FPG) by the glucose oxidase method and lipid profiles (TC, TG, LDL-C, and HDL-C) by enzymatic methods
Automated glycosylated hemoglobin analyzer	Tosoh Corporation (Japan)	G8	Measurement of glycated hemoglobin (HbA1c) by high-performance liquid chromatography
Bisphosphonate tablets	Qilu Pharmaceutical Co., Ltd., Jinan, China	H20041508	Anti-osteoporotic therapy (as clinically indicated)
Blood glucose meter	Sinocare Inc., Changsha, China	Safe-Accu 2	Daily fasting glucose monitoring
Calcium carbonate tablets	CSPC Pharmaceutical Group Ltd., Shijiazhuang, China	H13020505	Calcium supplementation (1000 mg/day)
Centrifuge	Xiangyi Centrifuge Instrument Co., Ltd., Changsha, China	TD5A-WS	Serum separation
Dual-energy X-ray absorptiometry bone densitometer	GE Healthcare (United States)	Lunar DPX	Measurement of lumbar spine L1-4 and left femoral neck bone mineral density (BMD)
Electronic medical record (EMR) system	Winning Health Technology Group Co., Ltd., Nanjing, China	HIS-V9.0	Extraction of clinical and nursing data
PASS 15.0	NCSS, LLC (United States)		Sample size calculation software
Self-Rating Anxiety Scale (SAS)	Zung / public clinical assessment scale	N/A	Assessment of anxiety using 20 items with a 4-point scoring system; cutoff value 50
Self-Rating Depression Scale (SDS)	Zung / public clinical assessment scale	N/A	Assessment of depression using 20 items with a 4-point scoring system; cutoff value 53
Social Support Rating Scale (SSRS)	Xiao Shuiyuan / public clinical assessment scale	N/A	Assessment of social support using 10 items with a total score range of 12-66
SPSS 26.0	IBM Corp. (United States)		Statistical software
Venous blood collection tubes	Improve Medical Instruments Co., Ltd., Guangzhou, China	695070	Serum sample collection
Vitamin D3; capsules	Zhejiang Medicine Co., Ltd., Xinchang, China	H20040198	Vitamin D supplementation (800 IU/day)
Web-based FRAX tool	University of Sheffield, Centre for Metabolic Bone Diseases (United Kingdom)	China-specific model	Calculation of 10-year probabilities of major osteoporotic fracture and hip fracture with femoral neck BMD included