OBJECTIVES: To compare a newly developed method to derive disability weights for risk factor diseases, in particular osteoporosis, with the standard QALY approach (SQA). A risk factor disease is an asymptomatic condition with a risk of a symptomatic event. SQA estimates burden of risk by multiplying the probability of an event by the burden of that event, ignoring the impact of risk awareness. In osteoporosis, fracture-risk awareness and associated mortality may affect the burden. METHODS: Disability weights were derived by a panel of the general public in the Netherlands (n=142) as part of a larger valuation study. All health states were presented to participants on a standardized, preformatted sheet (‘vignette') containing disease specific information and a generic description (EQ-6D5L). All vignettes were valued by TTO. Vignettes for osteoporosis showed an asymptomatic state with varying fracture-risks (1, 2, 5, or 10%), which were valued directly. To derive osteoporotic weights by SQA osteoporotic fracture vignettes were included. SQA weights were obtained indirectly; calculated as hip fracture weight multiplied by fracture risks. In total, 14 vignettes were valued, of which three included a mortality risk. RESULTS: Taking fracture-risk awareness into account, mean TTO disability weights for osteoporosis ranged from 0,035 (1%) to 0,151 (10%). Calculated SQA weights are 0,001 (1%) to 0,011 (10%), a factor 9 to 34 lower. CONCLUSIONS: The burden of disease in risk factor diseases (osteoporosis) can be quantified via disability weights using direct methods. Ignoring fracture-risk awareness and associated mortality leads to gross underestimation of the burden of osteoporosis. The inclusion of burden of risk would significantly influence current QALY/DALY disease rankings and would accommodate the empirical gap between SQA and the clinical practice. It would better explain the sizeable resources spent on risk ‘management' (eg diagnostic tests, disease surveillance) and prevention in terms of cost per QALY.