Closing the care gap: IOF position paper identifies barriers and solutions to global undertreatment of osteoporosis

The International Osteoporosis Foundation (IOF) has issued a landmark Position Paper identifying critical global barriers to osteoporosis care and calling for urgent change to improve access to effective fracture prevention strategies.

Osteoporosis is among the most common chronic non-communicable diseases, affecting approximately 500 million men and women worldwide. Approximately one in three women and one in five men aged over 50 will suffer an osteoporosis-related fracture in their remaining lifetimes. 

“Despite significant progress in the assessment and treatment of osteoporosis and related fracture risk over the past five decades, the majority of patients at high fracture risk still lack access to appropriate care,” said Professor Eugene McCloskey, Chair of the IOF Committee of Scientific Advisors, Mellanby Centre for Musculoskeletal Research, University of Sheffield, UK.

“Osteoporosis is now a manageable condition, yet advances in prevention and treatment have not translated into equitable care, particularly in under-resourced regions.”

Endorsed by more than 85 national and global organizations in the field, the Position Paper identifies a number of key obstacles, including limited availability of bone density (DXA) scanning, outdated treatment criteria that rely solely on bone mineral density (BMD), and confusion surrounding diagnostic versus intervention thresholds.

It urges a paradigm shift in how bone health in older age, including osteoporosis, is managed worldwide. Specifically, the IOF advocates for the recognition of “high fracture risk”—based on clinical risk factors with or without BMD—as a valid criterion for treatment and reimbursement. Consistent use of this approach would help ensure that patients who are most vulnerable, including those who have already suffered a fragility fracture, can access life-saving therapies even when DXA scans are unavailable.

The Position Paper emphasizes that DXA remains valuable where accessible, including for stratifying and monitoring treatment, and identifying hidden vertebral fractures. However, decoupling treatment eligibility from densitometry alone would offer a far more equitable and effective strategy for reducing the global burden of osteoporotic fractures.

Key messages include:

• Access to optimal bone health management is highly variable worldwide, with most patients at high fracture risk not receiving appropriate care.
• Confusion between diagnostic and intervention thresholds, together with lack of access to bone densitometry and other screening technologies, is a key consideration.
• The original WHO densitometric osteoporosis definition has advanced the field substantially and should be retained as a diagnostic criterion but not necessarily as an intervention criterion.
• Formalising the clinical use of the conceptual definition of osteoporosis may be superficially attractive but would be operationally limited.
• Moving to individualised absolute fracture risk, using clinical risk factors and additionally incorporating bone mineral density where available, theoretically offers the most equitable solution.
• Implementation would require recognition of a fracture risk criterion for reimbursement, for example “high fracture risk syndrome”, or simply “high fracture risk”.
• As is currently espoused in most guidelines, the occurrence of a fracture should remain an indication for consideration of antiosteoporosis treatment.

The IOF calls on the World Health Organization and national health authorities to support this reframing of osteoporosis care as part of a concerted Call to Action to ensure that all individuals at high fracture risk worldwide receive appropriate assessment and treatment to optimise their bone health.

Professor Nicholas Harvey, IOF President and Director of the MRC Lifecourse Epidemiology Centre, University of Southampton, UK, added: 

“This is an urgent global health issue. To make real progress, we need global advocacy, updated reimbursement policies, and national commitment to implementing fracture prevention strategies based on modern risk assessment methods.”

Read the full Position Paper in Osteoporosis International. 
 

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Reference:
Harvey, N.C., Al-Daghri, N., Beaudart, C. et al. Barriers and solutions for global access to osteoporosis management: a Position Paper from the International Osteoporosis Foundation. Osteoporos Int (2025). https://doi.org/10.1007/s00198-025-07628-5

About IOF
The International Osteoporosis Foundation (IOF) is the world’s largest nongovernmental organization dedicated to the prevention, diagnosis, and treatment of osteoporosis and related musculoskeletal diseases. IOF’s membership committees include leading scientific experts, 340 patient organizations and medical societies in more than 150 countries, as well as universities worldwide. The IOF Capture the Fracture® initiative counts over 1,200 Fracture Liaison Services across all regions of the world. Together, this global network works to prioritize bone health and fracture prevention, sharing a vision of a world free from fragility fractures, where healthy mobility is a reality for all. @iofbonehealth
Websites: www.osteoporosis.foundation ; www.capturethefracture.org ; www.worldosteoporosisday.org ; www.buildbetterbones.org ; www.iofacademy.org/