Plant-based diets, while perceived as healthy, raise emerging concerns, including a possible increased risk of bone fractures.

In recent years, plant-based diets (primarily vegetarian and vegan) have entered the public debate as synonymous with healthy eating. However, when we move beyond the prevailing narrative and look at individual clinical outcomes, critical areas emerge that cannot be ignored. One of these concerns is bone health, particularly the risk of fractures.

The reference point remains the landmark EPIC-Oxford study, published in 2020 in BMC Medicine by Tong et al. (“Vegetarian and vegan diets and risks of total and site-specific fractures: results from the prospective EPIC-Oxford study“). This is a prospective cohort of nearly 55,000 British adults followed for approximately 18 years. The results are clear: compared to meat eaters, vegetarians and pescetarians (those who exclude meat and poultry but consume fish) have a moderately increased risk of fractures, while vegans have more than double the risk of hip fractures. Vegans also have an increased risk of total fractures and fractures of some specific sites, such as the leg and vertebrae.

Vegan diets: even careful planning may not fully mitigate bone health risks

This finding remains highly significant, even after adjusting for important factors such as BMI, calcium and protein intake. This point is crucial because it refutes a widespread simplistic explanation: “It’s not the vegan diet itself; it’s just that they eat poorly. “The fact that these subjects still show a higher risk of fracture after adjusting for these factors calls into question the assumption that plant-based diets are nutritionally equivalent to omnivorous models if “well-planned. “

Evidence indicates that the problem isn’t limited to individual deficiencies, but concerns the overall nutritional makeup of these diets, particularly vegan ones, and their long-term impact on bone health. In other words, the data suggest that the plant-based dietary pattern may have inherent limitations for maintaining skeletal integrity, and that other factors are at play, related to the overall dietary pattern rather than just individual nutrients.

Fracture and osteoporosis risk in vegetarians compared with omnivores

In subsequent years, these findings have not been refuted. On the contrary, a new meta-analysis published in 2025 in Nutrition Reviews (Ballarin et al., “Vegetarian and Vegan Diets and the Risk of Hip Fracture in Adults: A Systematic Review and Meta-analysis“) that combined four large cohort studies totalling over 500,000 participants confirmed these findings. Vegetarians show an increased risk of hip fracture of approximately 25%, while vegans have an increase of approximately 75% compared to omnivores.

This evidence was further confirmed by another very recent, large-scale meta-analysis published in 2025 in Clinical Nutrition (Zheng et al., “Plant-based diet and risk of osteoporosis: A systematic review and meta-analysis“). The review included 20 studies with over 243,000 participants, comparing vegetarians and vegans with omnivorous dieters. The results show that plant-based diets are associated with a significantly increased risk of lumbar spine osteoporosis, with more pronounced signs in vegans and subjects who have followed such diets for more than 10 years.

This increased fracture risk has a biological basis. The meta-analysis published in Nutrition Reviews in 2019 (Iguacel I et al. “Veganism, vegetarianism, bone mineral density, and fracture risk: a systematic review and meta-analysis“) had already clearly shown that vegetarians and vegans have lower bone mineral density, especially in the lumbar spine and femoral neck. The differences become clinically relevant in the long term, especially with advancing age.

Ignoring these findings is not compatible with an evidence-based medical approach.

From a nutritional standpoint, the explanations are far from speculative. Scientific reviews on bone mineral density, including an Italian review published in Frontiers in Endocrinology in 2022, show that in plant-based diets, particularly vegan ones, calcium intake tends to be lower if fortified foods are not systematically used. Vitamin D is often insufficient. Protein intake, especially in less-structured versions of the diet, may be inadequate to maintain bone mass. Added to this is a lower average BMI, which represents an independent risk factor for hip fractures.

Finally, deficiencies of vitamin B12, zinc, selenium and other nutrients involved in bone remodelling processes and often critical in exclusively plant-based diets should not be overlooked (see also, for this purpose, the systematic review published in Nutrients in 2021, “Nutrient Intake and Status in Adults Consuming Plant-Based Diets Compared to Meat-Eaters: A Systematic Review“).

Overall, all available evidence indicates that plant-based diets, especially vegan ones, are not neutral with respect to skeletal health. On the contrary, they are consistently associated with an increased risk of fractures, particularly hip fractures. This finding must be taken into account in clinical practice, especially in older individuals, postmenopausal women, and those with existing risk factors for osteoporosis.

Ignoring or downplaying these findings for ideological reasons is not compatible with an evidence-based medical approach.