Osteoporosis in Italy: prevalence, impact, and what to know

Initial note: this article is an updated version of previously published content, re-elaborated according to scientific and informative criteria. It is for informational purposes only and does not replace medical advice.

IN BRIEF

• DXA studies on Italian samples indicate that about one-third of postmenopausal women are osteoporotic and a significant proportion have osteopenia; many are unaware of the risk.
• Osteoporosis increases the risk of fractures (femur, vertebrae, wrist) with significant clinical repercussions and costs for the healthcare system.
• Tools such as densitometry (DXA) and risk scores (e.g., FRAX) help identify at-risk individuals, but they have limitations and do not replace overall clinical evaluation.
• Available treatments reduce fracture risk in selected populations, but efficacy varies with risk profile and treatment adherence.
• In Italy, gaps persist in diagnosis and treatment continuity; targeted screening strategies and secondary prevention services (e.g., Fracture Liaison Service) can improve outcomes.

Abstract: what does science say?

Osteoporosis is a condition of reduced bone mass and microarchitectural alteration that increases the likelihood of fragility fractures. Studies conducted in Italy using densitometry (DXA) on representative samples have estimated the presence of osteoporosis in approximately one-third of postmenopausal women, with an even larger proportion affected by osteopenia. Experimental and review evidence indicates that anti-fracture therapies—particularly anti-resorptive classes like bisphosphonates—can reduce the risk of vertebral fractures and, in selected populations, also non-vertebral and hip fractures. However, the net effect depends on patient selection (prevalence of low BMD, fracture history), treatment adherence, and the limitations of screening tools and observational studies. In Italy, the disease entails a significant clinical and economic burden, exacerbated by a large gap in initiating therapy after fractures. Current recommendations favor targeted screening in the elderly and the use of risk tools integrated with densitometry, always interpreted within the individual clinical context.

Epidemiology and prevalence in Italy

Italian surveys conducted with densitometry (DXA) on representative samples provide useful data for understanding the extent of the problem. In a national cohort of almost 1,000 postmenopausal women evaluated with DXA, a prevalence of osteoporosis of approximately 34% and osteopenia of almost 47% was observed; the proportion of women with a history of fragility fracture was also significant. These results place Italy among the countries with a notable prevalence of low bone mass in the elderly female population [1].

It is important to emphasize that prevalence varies depending on age, measurement site (spine vs. femoral neck), methods used, and characteristics of the studied population (e.g., body mass index, reproductive history, lifestyle habits). Studies on Italian regions and literature reviews show some heterogeneity but converge in recognizing an increase in prevalence with age and a consistent burden of bone fragility-related fractures [1][2].

Diagnosis: DXA, FRAX, and limitations of tools

Bone densitometry with DXA remains the standard for measuring bone mineral density and defining the diagnosis of osteoporosis according to international thresholds. However, density alone does not capture all risk factors: clinical risk scores (such as FRAX) integrate demographic and clinical variables to estimate the 10-year fracture probability and guide diagnostic and therapeutic choices [2].

The combined use of DXA and FRAX improves risk stratification: densitometry quantifies bone mass deficit, while FRAX places BMD in a context of clinical factors (age, previous fractures, glucocorticoid use, other conditions). However, both tools have limitations: FRAX can underestimate risk in some populations and does not consider certain factors (e.g., the recency of a fracture), while DXA does not measure bone quality and may show discordance between scan sites [3][8].

Limitations of screening and criteria for DXA referral

Policy recommendations emphasize the need for targeted screening: many guidelines suggest performing DXA in women aged ≥65 years or earlier if clinical risk factors that increase the likelihood of osteoporosis exist. Indiscriminate application of DXA to the menopausal population is not considered an efficient use of resources; rational decisions require clinical rules and cost/benefit evaluations. Furthermore, the sensitivity and specificity of selection algorithms vary, so the choice of criteria must consider the local context and service availability [1][8].

Clinical and economic consequences

Fragility fractures—particularly those of the hip and spine—are associated with significant morbidity, loss of autonomy, and increased short- and medium-term mortality. Disease burden analyses in Europe place osteoporotic fractures among the leading causes of disability in older people; the overall economic cost for European states is significant and includes hospitalizations, rehabilitation, and long-term care [2].

In Italy, studies based on real-world data show a significant treatment gap after fracture and substantial costs for the healthcare system: recent regional analyses have estimated significant direct costs per patient in the first year after a hip fracture and documented that a large majority of patients did not receive anti-osteoporotic therapy in the months following hospitalization, a phenomenon that increases the risk of new fractures and additional costs [3].

Treatments: efficacy and limitations of evidence

Experimental literature and systematic reviews indicate that different classes of anti-osteoporosis drugs reduce fracture risk in selected populations. Bisphosphonates (e.g., alendronate, risedronate, zoledronate) are among the most studied classes and are associated with significant reductions in the risk of vertebral fractures and—in certain clinical contexts—non-vertebral and hip fractures. Meta-analyses and targeted reviews show that the magnitude of risk reduction depends on the type of fracture, initial risk profile, and treatment adherence [5][6].

Comparative efficacy and in real-world populations

Bayesian analyses and network meta-analyses comparing bisphosphonates with each other and with other therapies show an overall anti-fracture effect, with variability for individual drugs and populations. Cochrane reviews and large syntheses agree that clinical benefits are clearer in people with very low BMD or with previous fractures; the effect in low-risk primary populations is more modest and less robustly documented [5][6][7].

What this means in practice

For citizens and healthcare professionals, the practical message is multi-level. First, the presence of risk factors (advanced age, previous fractures, chronic therapies that damage bone, low BMI, smoking, low physical activity) requires an assessment of the overall fracture risk and, when indicated, the performance of DXA. Decisions to test and treat should not be automatic but based on a combination of clinical factors and individual fracture probability.

For people who have already experienced a fragility fracture, evidence strongly supports the activation of a secondary prevention pathway (comprehensive evaluation, initiation of anti-fracture therapy when appropriate, support for adherence). In Italy, there are experiences and tools to optimize the cost/benefit ratio of diagnostics and therapy; however, their diffusion is not yet uniform, which contributes to a high treatment gap after fracture [1][3].

Key takeaways

• Osteoporosis is common in older women and often remains undiagnosed until fractures occur.
• DXA is the reference tool for measuring bone density, but risk assessment must integrate clinical factors with tools like FRAX.
• Anti-fracture drugs reduce risk in selected populations; the effect is greater in the presence of very low BMD or previous fractures.
• There is a wide gap between patients who suffer fractures and those who receive adequate treatment; improving therapeutic continuity is a public health priority.
• Effective prevention combines risk assessment, targeted diagnosis, lifestyle interventions, and organizational pathways for post-fracture management.

Limitations of evidence

It is essential to distinguish between observed associations and causal evidence certified by randomized trials. Much information on prevalence and correlations with risk factors comes from observational studies, which are useful for describing the phenomenon but are subject to confounding and selection bias. Randomized clinical trials provide the best evidence on drug efficacy, but they often include selected patients and study conditions that do not exactly reproduce real clinical practice [5][6][7].

Some recurring methodological limitations include: heterogeneity in inclusion criteria between studies, limited follow-up duration compared to the natural course of the disease, variability in outcome definition (radiographic vs. clinical), and poor representativeness of particular groups (men, frail elderly with comorbidities). For economic studies, the availability and quality of regional real-world data can influence cost estimates. For all these reasons, recommendations must be interpreted with caution and adapted to the individual clinical context [2][3][5].

Editorial conclusion

In Italy, densitometric data on representative cohorts show a significant prevalence of osteoporosis and osteopenia among postmenopausal women; this problem translates into an increased risk of fractures, loss of autonomy, and significant healthcare burdens. The most effective strategies are not indiscriminate screening but the structured identification of high-risk individuals, the integrated use of DXA and risk tools, access to anti-fracture therapies when appropriate, and the activation of secondary prevention pathways after fractures.

For healthcare decision-makers, priorities are: disseminating care pathways that reduce the post-fracture treatment gap, improving the selection of individuals to be referred for DXA with validated rules, and supporting education and treatment adherence programs. For citizens, consulting a doctor for a risk assessment remains the key step: early diagnosis and continuity of care are crucial for reducing the impact of fractures.

Editorial note

This article updates and synthesizes evidence published in peer-reviewed literature and policy recommendations available as of the update date. The purpose is informative and educational: it does not replace individual clinical advice. For diagnostic and therapeutic questions, consult your primary care physician or a specialist.

SCIENTIFIC RESEARCH

1. D'Amelio P, Spertino E, Martino F, Isaia G C. Prevalence of Postmenopausal Osteoporosis in Italy and Validation of Decision Rules for Referring Women for Bone Densitometry. Calcified Tissue International. 2013;92:437–443. https://doi.org/10.1007/s00223-013-9699-5
2. Svedbom A, Hernlund E, Ivergård M, et al. Osteoporosis in the European Union: a compendium of country‑specific reports. Archives of Osteoporosis. 2013;8:137. https://doi.org/10.1007/s11657-013-0137-0
3. Willers C, et al. Burden of Disease and Treatment Gap in Patients with an Osteoporotic Hip Fracture between 2015 and 2019 in Italy. Drugs & Aging. 2025; (Article). https://doi.org/10.1007/s40266-025-01211-7
4. Kanis JA, Johnell O, Oden A, et al. FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporosis International. 2008;19:385–397. https://doi.org/10.1007/s00198-007-0543-5
5. Anti‑Hip Fracture Efficacy of Bisphosphonates: A Bayesian Analysis of Clinical Trials. Journal of Bone and Mineral Research. 2006;21:340–349. https://doi.org/10.1359/JBMR.050903
6. Clinical effectiveness of bisphosphonates for the prevention of fragility fractures: A systematic review and network meta‑analysis. Bone. 2016;89:52–58. https://doi.org/10.1016/j.bone.2016.05.013
7. Cochrane Review: Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. (CD004523). https://doi.org/10.1002/14651858.CD004523
8. U.S. Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: Recommendation Statement. JAMA. 2018;319(24):2521–2531. https://doi.org/10.1001/jama.2018.7498

Notes on references and names cited in the article: the data and citations reported refer exclusively to verified publications and information contained in the original article; the names and roles cited from the original text (Giancarlo Isaia, Claudia Matta) have been maintained without additional biographical information.