Intended for healthcare professionals

Rapid response to:

Analysis Too Much Medicine

Overdiagnosis of bone fragility in the quest to prevent hip fracture

BMJ 2015; 350 doi: (Published 26 May 2015) Cite this as: BMJ 2015;350:h2088

Rapid Response:

Re: Overdiagnosis of bone fragility in the quest to prevent hip fracture

Dear Editor,

The International Osteoporosis Foundation (IOF) deems this article inaccurate and misleading on a number of levels. Some of the authors’ key misconceptions are addressed below, particularly in relation to their main conclusion that “The dominant approach to hip fracture prevention is neither viable as a public health strategy nor cost effective”.

IOF agrees that the majority of hip fractures in older people occur after a fall. However, many people would not fracture if they did not have underlying osteoporosis. Other osteoporotic fractures can occur as a result of a minor bump, sneeze or even bending over to tie a shoelace. Hip fractures cause the greatest morbidity with reported mortality rates up to 20-24% in the first year after a hip fracture. Hip fractures have a devastating impact on a person’s quality of life and cause loss of function and independence with: 40% unable to walk independently; 60% requiring assistance a year later; 33% being totally dependent on or in a nursing home in the year following a hip fracture. In addition, hip fractures have large economic consequences and account for 17% of all osteoporotic fractures in Europe but comprise 54% of the direct cost of fractures.

The harsh reality is that we know that osteoporosis and related fractures are under- not over-diagnosed as the authors suggest. The need for appropriate management, including pharmacotherapy, arises because of the increased risk of a second fracture, which is particularly acute in the immediate post-fracture period when fracture rates are substantially increased (1).

The article states that organizations supporting the development of FRAX® are advocating for widespread screening of all postmenopausal women and men aged >50 years, this is simply not true. The IOF position is that anyone aged over 50 years who has suffered a previous fracture should speak to their health-care professional about getting tested for osteoporosis.

The authors also state that “Overdiagnosis of bone fragility leads to overtreatment”, in fact the number of people being treated – even after a hip fracture – is alarmingly low. Evidence shows that there is a major care gap in patients being appropriately managed to avoid secondary fractures, even though a prior fracture is associated with an 86% increased risk of any fracture. Fewer than 20% of individuals receive therapy to reduce the risk of future fracture within the year following the fracture. The therapeutic care gap may be particularly wide in the elderly in whom the importance and impact of treatment is high; studies have shown that as few as 10% of older women with fragility fractures receive any osteoporosis therapy (oestrogens not considered) (1).

They continue by saying that “drug treatments eclipsed other forms of treatment such as lifestyle modification and physical activity”. However, IOF and its more than 230 member organizations, including patient and medical societies from over 95 countries, advocate for a systematic approach to osteoporosis and hip fracture prevention. We support an integrated approach to osteoporosis and falls prevention and educate people on the importance of eating bone-healthy foods, exercising, and avoiding tobacco and harmful use of alcohol. Consensus guidelines on fragility fracture prevention also reflect this. In addition, osteoporosis treatment guidelines recommend lifestyle modifications in conjunction with pharmacological interventions; further, many guidelines only recommend these interventions in men and women who have sustained a fragility fracture. However, the views expressed by the authors of the current article do not recognize this.

Treatment is critical for patients at high-risk of fracture and a 30–50% reduction in fracture incidence can be achieved with 3 years of pharmacotherapy (2). There is strong evidence to demonstrate that: osteoporosis treatments reduce fracture risk among patients at high risk of suffering fragility fractures; and that certain falls interventions reduce the risk of further falls among high-risk patients. This again disputes the authors’ claims that this evidence is lacking.

Organizations such as IOF have a responsibility to protect the bone health of people globally. Our strategy is entirely focused on identification of individuals who will suffer a fracture in the absence of interventions to reduce bone fragility or falls risk, and capture people after their first fracture.

This is why IOF advocates for the implementation of Fracture Liaison Services (FLS) through its Capture the Fracture® programme to help close the care gap. FLS provide a robust mechanism to ensure that patients presenting with fragility fractures receive assessment for osteoporosis and falls risk as well as treatment in accordance with national guidelines so that they avoid the fracture cascade. The current paper adds no constructive contribution to that effort, and indeed undermines it.

These authors’ views are at odds with the overwhelming majority of their peers and further, such articles have the potential to discourage people who are high risk of fracture, who are currently undergoing fracture preventive measures, from adhering to their evidence-based management plans. A direct consequence of that might be self-selected discontinuation of treatment, resulting in some individuals suffering hip fractures that might otherwise have been prevented. An ironic, and indeed tragic outcome of this misrepresentative paper.

Prof. John A. Kanis,
President, International Osteoporosis Foundation


1. Kanis JA, Svedbom A, Harvey N, McCloskey EV. The Osteoporosis Treatment Gap. JBMR 2014; 9: 1926–1928.
2. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age and ageing 2010; 39: 412–423.

Competing interests: Prof. John A. Kanis developed the FRAX® tool in collaboration with the World Health Organization.

01 June 2015
John A. Kanis
President, International Osteoporosis Foundation
Prof. Cyrus Cooper, Prof. René Rizzoli, Prof. Bess Dawson-Hughes, Prof. Jean-Yves Reginster
International Osteoporosis Foundation
Rue Juste-Olivier 9, CH-1260 Nyon, Switzerland