WHO osteoporosis definitions ignore child development stages. Misapplying adult DXA criteria overdiagnoses healthy kids, causing unnecessary treatment with highly toxic drugs like Fosamax whose risks remain under-recognized.
In 1994, the World Health Organization (WHO) put forth an operational definition for osteoporosis, classifying it as bone mineral density (BMD) 2.5 standard deviations below the mean peak bone mass of a young adult Caucasian woman, as measured by dual-energy x-ray absorptiometry (DXA).1 While ostensibly created for clinical and research purposes, this definition was conceived by a panel rife with conflicts of interest tied to pharmaceutical companies developing drug treatments.2
The WHO definition has been heavily criticized for lack of connection to fracture risk or morbidity, bias toward pharmaceuticalization, and failure to account for complex physiological factors.3,4
As Drs. Wright and Looker stated in 2003,
"The WHO criteria were never intended to constitute the definition of a disease, only to provide a practical tool for assessing risk of fracture."5
Regardless, through extensive marketing, the medical community rapidly adopted the WHO classification system. This catalyzed a massive expansion in DXA scanning to assess osteoporosis risk.6,7
Problems Applying WHO Criteria to Children
When applied to children, several major issues arise with the WHO osteoporosis classification system. First and foremost is the use of T-scores, which compare a child’s BMD to a young adult reference mean.8 As children have lower peak bone mass compared to adults, their T-scores will inevitably appear far below normal.9
Instead of T-scores, children should be assessed using Z-scores, which compare the child’s BMD to an age-matched mean.10 However, as pre-pubertal children have less sex hormone-mediated skeletal growth, their BMD can still appear reduced compared to pubertal children. This had led to calls for standards incorporating pubertal stages.11
Additionally, a child’s measured areal BMD depends greatly on their bone size,12 while fracture risk relates much more to volumetric BMD and bone microarchitecture.13 Research teams have worked for years to translate children’s DXA results into proper volumetric BMD Z-scores accounting for age, sex, puberty, size, and ethnicity to facilitate clinical interpretation.14,15
The myriad complexities in assessing children’s bone health makes it "impossible to diagnose osteoporosis" using DXA alone.16 Thus, the International Society for Clinical Densitometry recommends diagnosis incorporate thorough history, physical exam, DXA results, and validated methods to adjust BMD for body size.17
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High Rates of Misdiagnosis in Children
Despite long-standing guidance to properly interpret children’s DXA scans, concerning evidence indicates mistakes remain extremely common. A 2004 study found 88% of children with diagnosed low BMD had major errors in their interpretation.18 Strikingly, 53% were reclassified as normal BMD when properly analyzed by pediatric standards. Much of this overdiagnosis resulted from utilizing adult criteria to analyze children’s scans.
A 2015 study of Australasian pediatric centers found 63% of reporting clinicians utilized inappropriate T-scores to determine children’s DXA results.19 A survey of American pediatric orthopedists in 2018 showed only 34% correctly stated T-scores should not be used in children.20 Alarmingly, studies continue showing many healthy children mistakenly given osteoporosis diagnoses, causing unnecessary treatment and family distress.21,22
This evidence indicates guidelines for properly interpreting pediatric DXA scans have not been sufficiently implemented. Researchers suggest this failure reflects DXA results frequently being analyzed in high volume by technicians and physicians without specific pediatric training.18,23 Moving forward, providers with expertise in pediatric bone health must proactively engage community providers to prevent continued overdiagnosis of healthy children.24
The Context: Problems with the WHO Classification System
As highlighted by this evidence, extending the WHO osteoporosis classifications to children recurs the same problems as seen for adult definitions – overly simplistic numerical thresholds that ignore individual variability and complex physiological factors. The WHO system disregards salient clinical data on nutrition, genetics, hormonal exposures, bone geometry, and lifestyle to narrowly focus on DXA T-scores.25
Yet substantial evidence shows the WHO classifications provide little meaningful information on fracture risk beyond age and clinical risk factors alone.26,27 Regardless, extensive marketing led to rapid, widespread adoption of DXA screening and pharmacological treatment targeting WHO criteria.28,29 Usage further escalated after procedures were approved for insurance reimbursement in the United States.30,31
Public health advocates argue this massive expansion of osteoporosis diagnosis and treatment predominantly benefits equipment manufacturers and pharmaceutical companies, not patients.32
As entrepreneur Peter Diamandis stated,
"a billion-dollar industry has been built based on the marketing of fear."33
Concerning evidence links osteoporosis treatment overuse with serious adverse effects like heart disease, atrial fibrillation, esophageal cancer, and devastating bone decay.34-36
In totality, the WHO classification system fails to appropriately describe either children or adults’ true bone health and fracture risk. For children, applying inappropriate adult criteria due to lack of provider specialization causes frequent misdiagnosis of healthy pediatric patients. This reflects a larger issue - the erroneous overextension of arbitrary DXA thresholds absent nuanced clinical data. Moving forward, substantial reforms addressing the outsized influence of industry marketing on clinical standards seem necessary to prevent further overmedicalization in bone health policy.
Prevalence of Pediatric Osteoporosis Diagnoses and Associated Harms
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Despite lack of evidence supporting widespread bone density testing or osteoporosis diagnosis in children, concerning trends show increasing rates in recent decades. A US study found osteoporosis diagnosis in children <18 years old more than doubled from 1999 to 2014.37 By 2014, over 50,000 pediatric patients carried osteoporosis diagnoses.37 Surveys suggest up to 30-50% of children with brittle bone disease diagnoses may not meet appropriate clinical criteria.38
Once labeled with osteoporosis, children frequently receive drug interventions lacking safety data.
Bisphosphonates like Fosamax reduce bone turnover, but have been associated with devastating side effects like osteonecrosis of the jaw and atypical femoral fractures when used off-label in children.39-41 Yet these risks remain under-recognized, with one study showing only 26% of pediatricians were aware of bisphosphonate complications.42 More cautious approaches utilize rehabilitative strength training and nutrition modifications tailored to the individual child’s needs to support functional gains.43
The harms revealed by evidence argue against widespread early bone density testing and osteoporosis diagnoses in pediatric populations. Approaches should emphasize strengthening bone development through behavior and lifestyle alongside targeted medical therapies only where clinically indicated. As diagnoses multiply, we must critically monitor for overmedicalization that distresses families while exposing children to poorly tested pharmacological risks absent demonstrable benefit.
To learn more, reading Sayer Ji's article on the topic:
The Manufacturing of Bone Diseases: The Story of Osteoporosis and Osteopenia
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To learn more about natural ways to support bone health, visit our database on the subject.
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Learn more about the dangers of osteoporosis drugs here.
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