Bone turnover, calcium homeostasis, and vitamin D status in Danish vegans




A vegan diet has been associated with increased bone fracture risk, but the physiology linking nutritional exposure to bone metabolism has only been partially elucidated. This study investigated whether a vegan diet is associated with increased bone turnover and altered calcium homeostasis due to insufficient intake of calcium and vitamin D.


Fractionated and total 25-hydroxyvitamin D (25(OH)-D), parathyroid hormone (PTH), calcium, and four bone turnover markers (osteocalcin, N-terminal propeptide of type I procollagen (PINP), bone-specific alkaline phosphatase (BAP), and C-terminal telopeptide of type I collagen (CTX)) were measured in serum from 78 vegans and 77 omnivores.


When adjusting for seasonality and constitutional covariates (age, sex, and body fat percentage) vegans had higher concentrations of PINP (32 [95% CI: 7, 64]%, P = 0.01) and BAP (58 [95% CI: 27, 97]%, P < 0.001) compared to omnivores, whereas CTX (30 [95% CI: −1, 72]%, P = 0.06) and osteocalcin (21.8 [95% CI: −9.3, 63.7]%, P = 0.2) concentrations did not differ between the two groups. Vegans had higher serum PTH concentration (38 [95% CI: 19, 60]%; P < 0.001) and lower 25(OH)-D serum concentration (−33 [95% CI: −45, −19]%; P < 0.001), but similar serum calcium concentration (−1 [95% CI: −3, 1]%, P = 0.18 compared to omnivores.


Vegans have higher levels of circulating bone turnover markers compared to omnivores, which may in the long-term lead to poorer bone health. Differences in dietary habits including intake of vitamin D and calcium may, at least partly, explain the observed differences.

  • Subscribe to European Journal of Clinical Nutrition for full access:



Additional access options:

Already a subscriber?  Log in  now or  Register  for online access.


  1. 1.

    Davey GK, Spencer EA, Appleby PN, Allen NE, Knox KH, Key TJ. 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. 2003;6(3):259–69.

  2. 2.

    Appleby P, Roddam A, Allen N, Key T. Comparative fracture risk in vegetarians and nonvegetarians in EPIC-Oxford. Eur J Clin Nutr. 2007;61(12):1400–6.

  3. 3.

    Crowe FL, Steur M, Allen NE, Appleby PN, Travis RC, Key TJ. Plasma concentrations of 25-hydroxyvitamin D in meat eaters, fish eaters, vegetarians and vegans: results from the EPIC-Oxford study. Public Health Nutr. 2011;14(2):340–6.

  4. 4.

    Ho-Pham LT, Nguyen ND, Nguyen TV. Effect of vegetarian diets on bone mineral density: a Bayesian meta-analysis. Am J Clin Nutr. 2009;90:943–50.

  5. 5.

    Ho-Pham LT, Vu BQ, Lai TQ, Nguyen ND, Nguyen TV. Vegetarianism, bone loss, fracture and vitamin D: a longitudinal study in Asian vegans and non-vegans. Eur J Clin Nutr. 2012;66:75–82

  6. 6.

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

  7. 7.

    Kristensen NB, Madsen ML, Hansen TH, Allin KH, Hoppe C, Fagt S, et al. Intake of macro- and micronutrients in Danish vegans. Nutr J. 2015;14:115.

  8. 8.

    Aadahl M, Jorgensen T. Validation of a new self-report instrument for measuring physical activity. Med Sci Sports Exerc. 2003;35:1196–202.

  9. 9.

    Thuesen B, Husemoen L, Fenger M, Jakobsen J, Schwarz P, Toft U, et al. Determinants of vitamin D status in a general population of Danish adults. Bone. 2012;50:605–10.

  10. 10.

    Chan J, Jaceldo-Siegl K, Fraser GE. Serum 25-hydroxyvitamin D status of vegetarians, partial vegetarians, and nonvegetarians: the Adventist Health Study-2. Am J Clin Nutr. 2009;89(5):1686S–1692S.

  11. 11.

    Woitge HW, Scheidt-Nave C, Kissling C, Leidig-Bruckner G, Meyer K, Grauer A, et al. Seasonal variation of biochemical indexes of bone turnover: results of a population-based study. J Clin Endocrinol Metab. 1998;83:68–75.

  12. 12.

    Jorgensen NR, Mollehave LT, Hansen YBL, Quardon N, Lylloff L, Linneberg A. Comparison of two automated assays of BTM (CTX and P1NP) and reference intervals in a Danish population. Osteoporos Int. 2017;28:2103–13.

  13. 13.

    Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, et al. The2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011;96:53–58.

  14. 14.

    Nussbaum SR, Zahradnik RJ, Lavigne JR, Brennan GL, Nozawa-Ung K, Kim LY, et al. Highly sensitive two-site immunoradiometric assay of parathyrin, and its clinical utility in evaluating patients with hypercalcemia. Clin Chem. 1987;33:1364–7.

  15. 15.

    Brown JP, Albert C, Nassar BA, Adachi JD, Cole D, Davison KS, et al. Bone turnover markers in the management of postmenopausal osteoporosis. Clin Biochem. 2009;42:929–42.

  16. 16.

    Holick MF. Vitamin D deficiency. N Eng J Med. 2007;357:266–81.

  17. 17.

    Taylor CL, Patterson KY, Roseland JM, Wise SA, Merkel JM, Pehrsson PR, et al. Including food 25-hydroxyvitamin D in intake estimates may reduce the discrepancy between dietary and serum measures of vitamin D status. J Nutr. 2014;144:654–9.

  18. 18.

    Brot C, Vestergaard P, Kolthoff N, Gram J, Hermann AP, Sorensen OH. Vitamin D status and its adequacy in healthy Danish perimenopausal women: relationships to dietary intake, sun exposure and serum parathyroid hormone. Br J Nutr. 2001;86:S97–103.

  19. 19.

    Lamberg-Allardt C, Brustad M, Meyer HE, Steingrimsdottir L. Vitamin D—a systematic literature review for the 5th edition of the Nordic Nutrition Recommendations. Food Nutr Res. 2013;57.

  20. 20.

    Tripkovic L, Lambert H, Hart K, Smith CP, Bucca G, Penson S, et al. Comparison of vitamin D2 and vitamin D3 supplementation in raising serum 25-hydroxyvitamin D status: a systematic review and meta-analysis. Am J Clin Nutr. 2012;95:1357–64.

  21. 21.

    Kemi VE, Karkkainen MU, Karp HJ, Laitinen KA, Lamberg-Allardt CJ. Increased calcium intake does not completely counteract the effects of increased phosphorus intake on bone: an acute dose-response study in healthy females. Br J Nutr. 2008;99:832–9.

  22. 22.

    Lamberg-Allardt C, Karkkainen M, Seppanen R, Bistrom H. Low serum 25-hydroxyvitamin D concentrations and secondary hyperparathyroidism in middle-aged white strict vegetarians. Am J Clin Nutr. 1993;58:684–9.

  23. 23.

    Nordic Council of Ministers NCoM. Nordic nutrition recommendations 2012. Nord Nutr Recomm 2012. 2014;5:1–3.

  24. 24.

    Christiansen P, Steiniche T, Brixen K, Hessov I, Melsen F, Charles P, et al. Primary hyperparathyroidism: Biochemical markers and bone mineral density at multiple skeletal sites in Danish patients. Bone. 1997;21(1):93–99.

Download references


The authors would like to thank A Forman and T Lorentzen for technical assistance, and K Kaadtmann, T Toldsted, P Sandbeck and G Lademann for managerial assistance.


The Novo Nordisk Foundation Center for Basic Metabolic Research is an independent research centre at the University of Copenhagen partially funded by an unrestricted donation from the Novo Nordisk Foundation ( Funders had no influence on study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author contributions

THH, TH, HV, OP, and KHA designed research; THH, NRJ, and AC conducted research; THH and MTBM analyzed data; THH, MTBM, and KHA wrote the paper; KHA had primary responsibility for final content. All authors read and approved the final manuscript.

Author information


  1. The Novo Nordisk Foundation Center for Basic Metabolic Research, Section of Metabolic Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

    • Tue H. Hansen
    • , Marie T. B. Madsen
    • , Torben Hansen
    • , Henrik Vestergaard
    • , Oluf Pedersen
    •  & Kristine H. Allin
  2. Department of Clinical Biochemistry, Research Center for Ageing and Osteoporosis, Rigshospitalet, Glostrup, Denmark

    • Niklas R. Jørgensen
  3. OPEN, Odense Patient data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark

    • Niklas R. Jørgensen
  4. Danish Center for Neonatal Screening, Department Biobanks and Biomarkers, Statens Serum Institut, Copenhagen, Denmark

    • Arieh S. Cohen
  5. Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark

    • Torben Hansen
  6. Steno Diabetes Center Copenhagen, Gentofte, Denmark

    • Henrik Vestergaard
  7. Department of Clinical Epidemiology, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark

    • Kristine H. Allin


  1. Search for Tue H. Hansen in:

  2. Search for Marie T. B. Madsen in:

  3. Search for Niklas R. Jørgensen in:

  4. Search for Arieh S. Cohen in:

  5. Search for Torben Hansen in:

  6. Search for Henrik Vestergaard in:

  7. Search for Oluf Pedersen in:

  8. Search for Kristine H. Allin in:

Conflict of interest

The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Tue H. Hansen.

Electronic supplementary material