Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Original Article
  • Published:

Comparative fracture risk in vegetarians and nonvegetarians in EPIC-Oxford



To compare fracture rates in four diet groups (meat eaters, fish eaters, vegetarians and vegans) in the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Oxford).


Prospective cohort study of self-reported fracture risk at follow-up.


The United Kingdom.


A total of 7947 men and 26 749 women aged 20–89 years, including 19 249 meat eaters, 4901 fish eaters, 9420 vegetarians and 1126 vegans, recruited by postal methods and through general practice surgeries.


Cox regression.


Over an average of 5.2 years of follow-up, 343 men and 1555 women reported one or more fractures. Compared with meat eaters, fracture incidence rate ratios in men and women combined adjusted for sex, age and non-dietary factors were 1.01 (95% CI 0.88–1.17) for fish eaters, 1.00 (0.89–1.13) for vegetarians and 1.30 (1.02–1.66) for vegans. After further adjustment for dietary energy and calcium intake the incidence rate ratio among vegans compared with meat eaters was 1.15 (0.89–1.49). Among subjects consuming at least 525 mg/day calcium the corresponding incidence rate ratios were 1.05 (0.90–1.21) for fish eaters, 1.02 (0.90–1.15) for vegetarians and 1.00 (0.69–1.44) for vegans.


In this population, fracture risk was similar for meat eaters, fish eaters and vegetarians. The higher fracture risk in the vegans appeared to be a consequence of their considerably lower mean calcium intake. An adequate calcium intake is essential for bone health, irrespective of dietary preferences.


The EPIC-Oxford study is supported by The Medical Research Council and Cancer Research UK.

This is a preview of subscription content, access via your institution

Access options

Buy this article

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others


  • Allen NE, Appleby PN, Davey GK, Kaaks R, Rinaldi S, Key TJ (2002). The associations of diet with serum insulin-like growth factor I and its main binding proteins in 292 women meat-eaters, vegetarians, and vegans. Cancer Epidemiol Biomarkers Prev 11, 1441–1448.

    CAS  PubMed  Google Scholar 

  • Allen NE, Appleby PN, Davey GK, Key TJ (2000). Hormones and diet: low insulin-like growth factor-I but normal bioavailable androgens in vegan men. Br J Cancer 83, 95–97.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • American Dietetic Association; Dietitians of Canada (2003). Position of the American Dietetic Association and Dietitians of Canada: Vegetarian diets. J Am Diet Assoc 103, 748–765.

    Article  Google Scholar 

  • Barr SI, Prior JC, Janelle KC, Lentle BC (1998). Spinal bone mineral density in premenopausal vegetarian and nonvegetarian women: cross-sectional and prospective comparisons. J Am Diet Assoc 98, 760–765.

    Article  CAS  PubMed  Google Scholar 

  • Bingham SA, Gill C, Welch A, Day K, Cassidy A, Khaw KT et al. (1994). Comparison of dietary assessment methods in nutritional epidemiology: weighed records v. 24 h recalls, food-frequency questionnaires and estimated-diet records. Br J Nutr 72, 619–643.

    Article  CAS  PubMed  Google Scholar 

  • Chen Z, Kooperberg C, Pettinger MB, Bassford T, Cauley JA, LaCroix AZ et al. (2004). Validity of self-report for fractures among a multiethnic cohort of postmenopausal women: results from the women's health initiative observational study and clinical trials. Menopause 11, 264–274.

    Article  PubMed  Google Scholar 

  • Chiu JF, Lan SJ, Yang CY, Wang PW, Yao WJ, Su LH et al. (1997). Long-term vegetarian diet and bone mineral density in postmenopausal Taiwanese women. Calcif Tissue Int 60, 245–249.

    Article  CAS  PubMed  Google Scholar 

  • Davey GK, Spencer EA, Appleby PN, Allen NE, Knox KH, Key TJ (2003). EPIC-Oxford: lifestyle characteristics and nutrient intakes in a cohort of 33 883 meat-eaters and 31 546 non meat-eaters in the UK. Public Health Nutr 6, 259–269.

    Article  PubMed  Google Scholar 

  • Dawson-Hughes B (2003). Calcium and protein in bone health. Proc Nutr Soc 62, 505–509.

    Article  CAS  PubMed  Google Scholar 

  • Department of Health (1991). Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report on Health and Social Subjects: 41. HMSO: London.

  • Fontana L, Shew JL, Holloszy JO, Villareal DT (2005). Low bone mass in subjects on a long-term raw vegetarian diet. Arch Intern Med 165, 684–689.

    Article  PubMed  Google Scholar 

  • Ginty F (2003). Dietary protein and bone health. Proc Nutr Soc 62, 867–876.

    Article  CAS  PubMed  Google Scholar 

  • Holland B, Welch AA, Unwin ID, Buss DH, Paul AA, Southgate DAT (1991). McCance & Widdowson's The Composition of Foods. Royal Society of Chemistry: Cambridge, UK.

    Google Scholar 

  • Institute of Medicine (1997). Dietary reference intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. National Academy Press: Washington, DC.

  • Key TJ, Appleby PN, Spencer EA, Roddam AW, Neale RE, Allen NE (2007). Calcium, diet and fracture risk: a prospective study of 1898 incident fractures among 34 696 British men and women. Public Health Nutr (in press).

  • Kohlenberg-Mueller K, Raschka L (2003). Calcium balance in young adults on a vegan and lactovegetarian diet. J Bone Miner Metab 21, 28–33.

    Article  CAS  PubMed  Google Scholar 

  • Larsson CL, Johansson GK (2002). Dietary intake and nutritional status of young vegans and omnivores in Sweden. Am J Clin Nutr 76, 100–106.

    Article  CAS  PubMed  Google Scholar 

  • Lau EM, Kwok T, Woo J, Ho SC (1998). Bone mineral density in Chinese elderly female vegetarians, vegans, lacto-vegetarians and omnivores. Eur J Clin Nutr 52, 60–64.

    Article  CAS  PubMed  Google Scholar 

  • Lloyd T, Schaeffer JM, Walker MA, Demers LM (1991). Urinary hormonal concentrations and spinal bone densities of premenopausal vegetarian and nonvegetarian women. Am J Clin Nutr 54, 1005–1010.

    Article  CAS  PubMed  Google Scholar 

  • Marsh AG, Sanchez TV, Michelsen O, Chaffee FL, Fagal SM (1988). Vegetarian lifestyle and bone mineral density. Am J Clin Nutr 48, 837–841.

    Article  CAS  PubMed  Google Scholar 

  • New SA (2004). Do vegetarians have a normal bone mass? Osteoporos Int 15, 679–688.

    Article  PubMed  Google Scholar 

  • Outila TA, Karkkainen MU, Seppanen RH, Lamberg-Allardt CJ (2000). Dietary intake of vitamin D in premenopausal, healthy vegans was insufficient to maintain concentrations of serum 25-hydroxyvitamin D and intact parathyroid hormone within normal ranges during the winter in Finland. J Am Diet Assoc 100, 434–441.

    Article  CAS  PubMed  Google Scholar 

  • Parsons TJ, van Dusseldorp M, van der Vliet M, van de Werken K, Schaafsma G, van Staveren WA (1997). Reduced bone mass in Dutch adolescents fed a macrobiotic diet in early life. J Bone Miner Res 12, 1486–1494.

    Article  CAS  PubMed  Google Scholar 

  • Prentice A (2004). Diet, nutrition and the prevention of osteoporosis. Public Health Nutr 7, 227–243.

    Article  CAS  PubMed  Google Scholar 

  • Reed JA, Anderson JJ, Tylavsky FA, Gallagher Jr PN (1994). Comparative changes in radial-bone density of elderly female lacto-ovovegetarians and omnivores. Am J Clin Nutr 59, 1197S–1202S.

    Article  CAS  PubMed  Google Scholar 

  • Siani V, Mohamed EI, Maiolo C, Di Daniele N, Ratiu A, Leonardi A et al. (2003). Body composition analysis for healthy Italian vegetarians. Acta Diabetol 40, S297–S298.

    Article  PubMed  Google Scholar 

  • Smith AM (2006). Veganism and osteoporosis: a review of the current literature. Int J Nurs Pract 12, 302–306.

    Article  PubMed  Google Scholar 

  • Stata Corporation (2005). Stata Statistical Software: Release 9.0. Stata Corporation. College Station: TX.

  • Tesar R, Notelovitz M, Shim E, Kauwell G, Brown J (1992). Axial and peripheral bone density and nutrient intakes of postmenopausal vegetarian and omnivorous women. Am J Clin Nutr 56, 699–704.

    Article  CAS  PubMed  Google Scholar 

  • Waldmann A, Koschizke JW, Leitzmann C, Hahn A (2003). Dietary intakes and lifestyle factors of a vegan population in Germany: results from the German Vegan Study. Eur J Clin Nutr 57, 947–955.

    Article  CAS  PubMed  Google Scholar 

Download references


The EPIC-Oxford study is supported by The Medical Research Council and Cancer Research UK. We thank the participants in EPIC-Oxford.

Author information

Authors and Affiliations


Corresponding author

Correspondence to P Appleby.

Additional information

Guarantor: P Appleby.

Contributors: PA performed the statistical analyses and wrote the manuscript. AR and NA contributed to the design of the study, interpretation of the results and to the writing of the manuscript. TK is the principal investigator of the EPIC-Oxford study and contributed to the manuscript writing.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Appleby, P., Roddam, A., Allen, N. et al. Comparative fracture risk in vegetarians and nonvegetarians in EPIC-Oxford. Eur J Clin Nutr 61, 1400–1406 (2007).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


This article is cited by


Quick links