Abstract Background/Aims Osteoporosis and metabolic bone diseases (MBD) constitute major public health challenges, contributing to over 8.9 million fragility fractures annually worldwide. Despite therapeutic advances, disparities persist across gender, ethnicity, socioeconomic status, and geography. Women, older adults, and certain racial/ethnic groups (e.g., Hispanic and Asian populations in Western countries, Indigenous communities globally) remain disproportionately underdiagnosed and undertreated. Structural inequities in healthcare delivery, cultural perceptions of bone health, and unequal access to diagnostic tools (e.g., DXA scanning) exacerbate these gaps, limiting the reach of effective interventions. To synthesise current evidence on equity, diversity, and inclusion (EDI) in osteoporosis and MBD care within rheumatology, with emphasis on disparities in diagnosis, treatment access, and outcomes, and to identify strategies promoting inclusive clinical practice. Methods A scoping review was undertaken across PubMed, Web of Science, and Cochrane (2010-2025). Eligible studies reported on disparities in osteoporosis/MBD related to race/ethnicity, sex/gender, socioeconomic factors, geography, or healthcare access. Data were narratively synthesised into domains of diagnosis, treatment, and health outcomes. Results From 1,326 records screened, 94 studies were included. Findings demonstrated: 1. Diagnostic inequities: women are more frequently screened than men, yet men experience higher mortality after fractures. Minority populations had 20-40% lower DXA utilisation rates, even when risk profiles were equivalent. 2. Treatment disparities: post-fracture osteoporosis treatment rates remained suboptimal (30%) across cohorts, with significantly lower initiation among African American and Hispanic patients compared to White patients (odds ratio range 0.56-0.72). 3. Socioeconomic and geographic barriers: low-income populations faced reduced access to fracture liaison services, while rural communities reported fracture-to-treatment gaps exceeding 12 months. 4. Inclusion in research: women and White populations dominated clinical trial cohorts, while men, minority ethnic groups, and older adults with multimorbidity were consistently underrepresented, limiting generalisability of treatment outcomes. Conclusion Persistent inequities in osteoporosis and MBD care reflect systemic, structural, and cultural barriers within rheumatology. Efforts to embed EDI principles must include expanding culturally adapted education, enhancing access to DXA and fracture liaison services in underserved communities, diversifying clinical trial recruitment, and integrating sex- and gender-sensitive approaches into guidelines. Addressing inequities is not only a matter of justice but also critical for optimising outcomes and reducing the global burden of fragility fractures. Future work should evaluate equity-driven interventions, such as community-based screening and digital health outreach, to ensure inclusive and sustainable care delivery. Disclosure S. Roy: None.
Subham Roy (2026) studied this question.