Most older adults in southern Iran who have osteoporosis by bone density testing do not know they have the disease, and the overwhelming majority of those with a confirmed diagnosis are not taking osteoporosis medication. A cross-sectional analysis of 4145 participants in the Bushehr Elderly Health (BEH) Program, published in Archives of Osteoporosis, estimated that 1050 participants who underwent dual-energy X-ray absorptiometry (DXA) were underdiagnosed, corresponding to 73.06%, while 1328 were undertreated, corresponding to 92.41%.
Across both phases, the participants had a mean age of 65.5 years and 54.40% were female. Bone mineral density was measured with DXA, the standard method for establishing an osteoporosis diagnosis in clinical practice.
The researchers also calculated undertreatment against three international intervention thresholds. Using FRAX without BMD, 666 participants met the threshold but were not treated, a rate of 91.98%. Using major osteoporotic fracture (MOF) FRAX with BMD, the count was 836, or 90.96%. Using FRAX with trabecular bone score (TBS) for major osteoporotic fracture, it was 868, or 92.53%. The consistency of these figures across different assessment tools indicates that the treatment gap in this population is not an artifact of one particular risk-scoring method.
For underdiagnosis, male sex was associated with lower odds (OR = 0.57, P < 0.001), while each additional year of age raised the odds (OR = 1.05, P < 0.001). Asset ownership in the fourth quintile was also associated with lower odds of being undiagnosed (OR = 0.79, P = 0.028), and each additional year of education reduced the odds (OR = 0.96, P < 0.001). In other words, men, older participants, and those with less education were more likely to have osteoporosis on DXA without knowing it.
The pattern for undertreatment was similar but not identical. Male sex (OR = 0.37, P < 0.001), older age (OR = 1.07, P < 0.001), fewer years of education (OR = 0.95, P < 0.001), marital status (OR = 0.78, P = 0.013), and being disabled in instrumental activities of daily living (OR = 1.28, P = 0.003) were all significantly associated with not receiving osteoporosis medication. These associations held after adjustment in the regression models, pointing to demographic and socioeconomic factors as markers of who is most likely to miss out on treatment even when the disease has been detected by bone density measurement.
The study’s authors note that diagnostic and therapeutic facilities for osteoporosis exist, yet a significant proportion of older adults remain undiagnosed and untreated. They suggest this care gap may stem from various barriers, and that understanding the underlying reasons for these disparities is crucial for developing targeted interventions. Their conclusion calls for extensive interventions at the population level to fill the gap, raise awareness of osteoporosis as a growing public health concern, and provide access to treatment for the disease.
As a cross-sectional analysis, the study captures diagnosis and treatment status at the time of assessment rather than tracking individuals over time, and the reported associations identify factors linked to the gaps rather than proving why they occur. The authors state that further research is needed to investigate the causes. Even so, the scale of the shortfall is striking: in a program that actively measured bone density in thousands of older residents, roughly three in four participants meeting the T-score definition of osteoporosis had never received a clinical diagnosis, and more than nine in ten were not on medication.
The findings carry weight beyond Bushehr because the measurement was objective. The result is a direct quantification of the distance between what a bone density scan shows and what a patient has been told and prescribed, measured against both the T-score definition and three FRAX-based intervention thresholds.
For clinicians and health planners, the message is that bone density testing alone does not close the care loop. The significant associations with sex, age, education, asset level, marital status, and functional disability suggest that awareness and access, not the availability of densitometry, are the limiting steps in this population. The BEH Program data provide a baseline for interventions aimed at raising osteoporosis awareness and improving treatment access among older adults in Iran, where the authors describe the disease as a growing public health concern.
Subject of Research: Gaps in osteoporosis diagnosis and treatment among older adults in Iran
Article Title: The osteoporosis diagnosis and treatment gaps in Iranian older adults: Bushehr Elderly Health (BEH) Program
Article References: Hesari, E., Fahimfar, N., Khalagi, K., Yarmohammadi, H., Shahrousvand, S., Zarepour, P., Gharibzadeh, S., Mansourzadeh, M. J., Sahafiee, G., Farhadi, A., Larijani, B., Ostovar, A., & Sanjari, M. (2026). The osteoporosis diagnosis and treatment gaps in Iranian older adults: Bushehr Elderly Health (BEH) Program. Archives of Osteoporosis, 21(1), Article 158. https://doi.org/10.1007/s11657-026-01776-9
Image Credits: AI Generated
DOI: 10.1007/s11657-026-01776-9
Keywords: osteoporosis, older adults, Iran, Bushehr Elderly Health Program, DXA, bone mineral density, underdiagnosis, undertreatment, FRAX, T-score, cross-sectional study, health disparities
