Osteoporosis International

, Volume 28, Issue 5, pp 1507–1529 | Cite as

Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

  • N. C. W. Harvey
  • E. V. McCloskeyEmail author
  • P. J. Mitchell
  • B. Dawson-Hughes
  • D. D. Pierroz
  • J.-Y. Reginster
  • R. Rizzoli
  • C. Cooper
  • J. A. Kanis


This narrative review considers the key challenges facing healthcare professionals and policymakers responsible for providing care to populations in relation to bone health. These challenges broadly fall into four distinct themes: (1) case finding and management of individuals at high risk of fracture, (2) public awareness of osteoporosis and fragility fractures, (3) reimbursement and health system policy and (4) epidemiology of fracture in the developing world. Findings from cohort studies, randomised controlled trials, systematic reviews and meta-analyses, in addition to current clinical guidelines, position papers and national and international audits, are summarised, with the intention of providing a prioritised approach to delivery of optimal bone health for all. Systematic approaches to case-finding individuals who are at high risk of sustaining fragility fractures are described. These include strategies and models of care intended to improve case finding for individuals who have sustained fragility fractures, those undergoing treatment with medicines which have an adverse effect on bone health and people who have diseases, whereby bone loss and, consequently, fragility fractures are a common comorbidity. Approaches to deliver primary fracture prevention in a clinically effective and cost-effective manner are also explored. Public awareness of osteoporosis is low worldwide. If older people are to be more pro-active in the management of their bone health, that needs to change. Effective disease awareness campaigns have been implemented in some countries but need to be undertaken in many more. A major need exists to improve awareness of the risk that osteoporosis poses to individuals who have initiated treatment, with the intention of improving adherence in the long term. A multisector effort is also required to support patients and their clinicians to have meaningful discussions concerning the risk-benefit ratio of osteoporosis treatment. With regard to prioritisation of fragility fracture prevention in national policy, there is much to be done. In the developing world, robust epidemiological estimates of fracture incidence are required to inform policy development. As the aging of the baby boomer generation is upon us, this review provides a comprehensive analysis of how bone health can be improved worldwide for all.


Case Finding Disease Awareness Fragility Fracture Osteoporosis Policy Primary Prevention Prioritisation Secondary Prevention 


Compliance with ethical standards

Conflicts of interest

BD-H – none for this submission.

CC has received consultancy and honoraria from Alliance for Better Bone Health, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Servier, Takeda and UCB.

DDP – none for this submission.

EVM has no disclosures related to this work, and has received consultancy fees, honoraria and/or research funding from Alliance for Better Bone Health, Amgen, AstraZeneca, Consilient Healthcare, GSK, Internis, Lilly, Merck, Pfizer, Servier, Synexus, Tethys, UCB, Warner Chilcott and Wyeth.

JAK and PJM have undertaken consultancy for governments, national osteoporosis societies, healthcare professional organisations and private sector companies relating to systematic approaches to fragility fracture care and prevention.

JYR has no disclosures related to this work, and has received consultancy, lecture fees and grant support from Amgen, Analis, Asahi Kasei, Boehringer, Bristol Myers Squibb, Chiltern, Danone, Ebewee Pharma, Endocyte, Galapagos, GlaxoSmithKline, IBSA-Genevrier, Lilly, Merck Sharp and Dohme, Merckle, Negma, Novartis, NovoNordisk, NPS, Nycomed-Takeda, Organon, Pfizer, PharmEvo, Radius Health, Roche, Rottapharm, Servier, Teijin, Teva, Theramex, Therabel, UCB, Will Pharma, Wyeth, Zodiac.

NCWH has no disclosures related to this work, and has received consultancy, lecture fees and honoraria from Alliance for Better Bone Health, AMGEN, MSD, Eli Lilly, Servier, Shire, Consilient Healthcare and Internis Pharma.

PJM serves as a consultant to the International Osteoporosis Foundation and received remuneration for his contribution to this manuscript.

RR has received honoraria for participation in Advisory boards or speaker bureau fees from Danone, Labatec, Nestlé, and ObsEva.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2017

Authors and Affiliations

  • N. C. W. Harvey
    • 1
    • 2
  • E. V. McCloskey
    • 3
    • 4
    Email author
  • P. J. Mitchell
    • 5
    • 6
  • B. Dawson-Hughes
    • 7
  • D. D. Pierroz
    • 8
  • J.-Y. Reginster
    • 9
  • R. Rizzoli
    • 10
  • C. Cooper
    • 1
    • 11
  • J. A. Kanis
    • 12
    • 13
  1. 1.MRC Lifecourse Epidemiology UnitUniversity of Southampton, Southampton General HospitalSouthamptonUK
  2. 2.NIHR Southampton Biomedical Research CentreUniversity of Southampton and University Hospital Southampton NHS Foundation TrustSouthamptonUK
  3. 3.MRC ARUK Centre for Integrated Research in Musculoskeletal Ageing, Metabolic Bone CentreNorthern General HospitalSheffieldUK
  4. 4.Mellanby Centre for Bone ResearchUniversity of SheffieldSheffieldUK
  5. 5.Synthesis Medical NZ LtdAucklandNew Zealand
  6. 6.University of Notre Dame AustraliaSydneyAustralia
  7. 7.Jean Mayer USDA Human Nutrition Research Center on AgingTufts UniversityBostonUSA
  8. 8.International Osteoporosis Foundation (IOF)NyonSwitzerland
  9. 9.Department of Public Health, Epidemiology and Health EconomicsUniversity of LiègeLiègeBelgium
  10. 10.Division of Bone DiseasesGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
  11. 11.NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesUniversity of OxfordOxfordUK
  12. 12.Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical SchoolSheffieldUK
  13. 13.Institute for Health and AgingCatholic University of AustraliaMelbourneAustralia

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