Vegetarian and vegan diets and risks of total and site-specific fractures: results from the prospective EPIC-Oxford study

Tammy Tong*, Paul N. Appleby, Miranda E G Armstrong, Georgina Fensom, Anika Knuppel, Keren Papier, Aurora Perez-Cornago, Ruth C Travis, Timothy J. Key

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

78 Citations (Scopus)
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Background: There is limited prospective evidence on possible differences in fracture risks between vegetarians, vegans, and non-vegetarians. We aimed to study this in a prospective cohort with a large proportion of non-meat eaters.
Methods: In EPIC-Oxford, dietary information was collected at baseline (1993-2001) and at follow-up (≈2010). Participants were categorised into four diet groups at both time-points (with 29,380 meat eaters, 8037 fish eaters, 15,499 vegetarians, and 1982 vegans at baseline in analyses of total fractures). Outcomes were identified through linkage to hospital records or death certificates until mid-2016. Using multivariable Cox regression, we estimated the risks of total (n=3,941) and site-specific fractures (arm, n=566; wrist, n=889; hip, n=945; leg, n=366; ankle, n=520; other main sites i.e. clavicle, rib and vertebra, n=467) by diet group over an average of 17.6 years of follow-up.
Results: Compared with meat eaters and after adjustment for socio-economic factors, lifestyle confounders and body mass index (BMI), the risks of hip fracture were higher in fish eaters (hazard ratio: 1.26; 95% CI 1.02-1.54), vegetarians (1.25; 1.04-1.50) and vegans (2.31; 1.66-3.22), equivalent to rate differences of 2.9 (0.6-5.7), 2.9 (0.9-5.2) and 14.9 (7.9-24.5) more cases for every 1000 people over 10 years respectively. The vegans also had higher risks of total (1.43; 1.20-1.70), leg (2.05; 1.23-3.41) and other main site fractures (1.59; 1.02-2.50) than meat eaters. Overall, the significant associations appeared to be stronger without adjustment for BMI, and were slightly attenuated but remained significant with additional adjustment for dietary calcium and/or total protein. No significant differences were observed in risks of wrist or ankle fractures by diet group with or without BMI adjustment, nor for arm fractures after BMI adjustment.
Conclusions: Non-meat eaters, especially vegans, had higher risks of either total or some site-specific fractures, particularly hip fractures. This is the first prospective study of diet group with both total and multiple specific fracture sites in vegetarians and vegans, and the findings suggest that bone health in vegans requires further research.
Original languageEnglish
Article number353 (2020)
Number of pages15
JournalBMC Medicine
Publication statusPublished - 23 Nov 2020

Structured keywords

  • SPS Exercise, Nutrition and Health Sciences


  • vegetarian diets
  • vegan diets
  • Fractures
  • bone health
  • Calcium
  • Protein
  • body mass index
  • prospective study


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