For 30 years osteoporosis has been defined as a bone mineral density more than 2.5 standard deviations below the mean value in the young normal population. However, multiple studies have shown that 80% of older adults suffering fractures do not meet this definition. As a result, treatment is often denied those who at high fracture risk and greatly in need of intervention. We need to move away from a rigid diagnostic definition based on only a single risk factor, to a broader set of thresholds which allow for cost-effective fracture prevention strategies. Without such a change in approach, the ageing of our community will result in ever increasing numbers of fractures, with the morbidity and mortality resulting from that.