Bone health and plant-based diets

 

During the past few years veganism has been on the rise. People following an exclusively plant-based diet may still only represent two per cent of the British population (i), but the numbers are growing steadily. For instance, according to a report on the future of food by the supermarket Sainsbury’s, by 2025 vegans along with vegetarians look set to make up a quarter of the population (ii).
 
There are many reasons why people give up eating meat (and, in the case of vegans, all other animal-sourced products including eggs and dairy too). Many vegans eat only plant-based foods because it’s kinder to animals. And with a 2023 report by the Climate Change Committee calling for the UK to reduce its meat and dairy consumption by 20 per cent by 2030 to help tackle climate change (iii), some do it for the good of the planet. Since it’s now widely believed that eating too much red and processed meat may be bad for your health in several ways, others also go meat free to be healthy.
 
But when it comes to bone health, could following a vegan diet be problematic? After all, we know calcium – one of the main sources for which is dairy foods – is essential for healthy bones. But if you don’t eat dairy, how can you get enough calcium in your diet? Could eating an exclusively plant-based diet set you up for developing a bone condition such as osteoporosis later in life?
 

What do the experts say?

 
Recent studies have found that both vegans and vegetarians may have a higher risk of bone fractures than meat eaters, which seems to suggest their bones aren’t as strong as those of carnivores.
 
One particular study – an analysis of information taken from the EPIC-Oxford study – received a lot of press attention when it was published in 2020 after it found vegans may have a higher fracture risk than meat eaters (iv). According to the statistics the report uncovered, over the course of 10 years vegans experience 20 more broken bones for every 1,000 people (think of it this way – if you were to compare a thousand vegans with a thousand omnivores, the vegan group would have 20 more fractures during a 10-year period). However some experts have described this increased risk for vegans as ‘modest’ and ‘relatively small’ (v).
 
Meanwhile other studies have also suggested vegetarians and vegans have lower bone densities than those who eat meat, with one estimating vegetarians have a bone density that’s four per cent lower than that of meat eaters (vi).
 
The overall picture, however, is mixed. For instance:
 

• One review of studies on the effects of vegetarian diets on bone health concludes that while some studies show significantly lower bone densities in vegetarians – especially vegans – others haven’t found any difference in bone health between vegetarians and meat eaters at all (vii)

• Research involving more than 9,600 older people in China suggests those following a healthy plant-based diet – particularly women – may actually have a lower risk of developing osteoporosis (viii). The researchers went so far as to suggest that a diet high in plant foods may even be associated with a higher bone mineral density. 

• Another review of studies concludes ‘there is no evidence that a plant-based diet, when carefully chosen to maintain adequate calcium and vitamin D levels, has any detrimental effects on bone health’ (ix)

 
This strongly suggests it’s highly possible to follow a plant-based diet and still have healthy bones – as long as you eat the right foods containing bone health nutrients and take supplements to ensure good levels of these nutrients if you need to.
 

Plant foods for healthy bones

 
A well-thought-out, well-balanced vegetarian or vegan diet can supply the nutrients you need for good bone health, including calcium, vitamin D, vitamin K, protein, magnesium, vitamin C and zinc.
 

Calcium  

 
You need calcium because it gives your bones their hardness and strength (indeed around 99 per cent of the calcium in your body is found in your bones).
 

• Most adults aged 19 years or older need 700mg of calcium a day

• Vegetarians can get calcium from dairy foods such as milk, cheese and yoghurt (dairy products are one of the main sources of calcium in the UK diet for omnivores too)

• Vegetarians and vegans can also get calcium from fortified plant-based alternatives to milk, cheese and yoghurt as well as other calcium-fortified foods such as breakfast cereals and bread plus other products made with calcium-fortified flour.

• Vegetables that contain calcium include broccoli, spring greens and other green leafy veg (spinach, however, includes a compound that may reduce calcium absorption). Other plant-based calcium-containing foods include beans, chickpeas and tofu. Some food manufacturers even add extra calcium to their tofu – this is called calcium-set tofu – which makes it an even richer source.

 
If you’re at risk of not getting enough calcium in your diet it’s a good idea to consider taking a calcium supplement. However not all calcium supplements are suitable for vegans, so always check the label.
 

Vitamin D  

 
The good news is our main source of vitamin D is suitable for most people, regardless of diet. Exposing your skin to strong sunlight causes a chemical reaction that results in your body making its own vitamin D.
 
You need vitamin D for bone health as it helps your body absorb calcium from food and supplements. Even if you eat plenty of foods that contain calcium, if you don’t get enough vitamin D your bones may not be healthy because your body won’t be able to absorb the calcium your bones need.
 
Vitamin D is found in a small number of foods, and according to the NHS it’s difficult to get enough from food alone (x). It’s even more difficult if you’re a vegetarian or vegan:
 

• Omnivores can get vitamin D from animal-based foods such as oily fish, red meat and offal (eg liver, kidneys etc)

• Vegetarians can get some vitamin D from egg yolks, but for vegans the main source is fortified foods such as plant milks, breakfast cereals and margarine (some mushrooms that were exposed to sunlight while growing may contain some vitamin D)

 
The fact that vitamin D isn’t found in that many foods contributes to the fact that many people – not just vegans and vegetarians – are considered at risk of having low vitamin D levels during the autumn and winter. That’s because there’s not enough strong sunlight in the UK and other northern hemisphere countries at that time of year to help our bodies make their own supply, and there aren’t enough food sources to make up for the shortfall.
 
Some people are also at risk of having low vitamin D all year round, including those who are housebound or don’t get out much, people who keep their skin covered when outdoors and those with darker skin.
 
Since vitamin D is important not just for bone health but other functions too – including immune health, for instance – the UK government says everyone should consider taking a daily supplement containing 10 micrograms of vitamin D during the autumn and winter months (those at high risk of also not getting enough vitamin D at other times should consider taking a supplement all year round too).
 
Supplements containing vitamin D3 (cholecalciferol) are often recommended as they provide the type of vitamin D your skin makes when it’s exposed to sunlight. Vegans should always check a vitamin D3 supplement is suitable for them, as some are derived from animal sources (D3 supplements derived from lichen are vegan friendly, whereas those derived from lanolin, or sheep’s wool, are not).
 

Vitamin K

 
While many of us are aware of the importance of calcium and vitamin D for bone health, fewer may have heard about the role vitamin K plays in keeping bones strong.
 
An important nutrient for blood clotting, vitamin K helps your body make essential bone proteins that help strengthen your bones. It also helps the calcium that’s absorbed from your food to get to your teeth and bones instead of accumulating in soft tissues. Vitamin K2 is thought to be particularly important for your bones – though they won’t thank you if you’re low in vitamin K1 either.
 
According to the NHS adults need around one microgram of vitamin K a day for each kilogram of their body weight (xi).
 

• You can find vitamin K1 in plant foods such as spinach broccoli, asparagus, kale, cabbage, Brussel sprouts and plant oils

• Vegetarians can get vitamin K2 from butter, egg yolks, hard cheeses such as Edam, Emmental and Gouda, as well as kefir, which is a fermented milk drink

• Vegans don’t have many K2 sources – fermented foods such as sauerkraut and natto (a fermented soya food) are the main options

 
Another way to get the vitamin K you need is to take a supplement, though check to make sure any supplement you’re considering taking is vegetarian or vegan friendly before you buy.
 
Find out more about calcium, vitamin D and vitamin K and their role in bone health by reading our article Bone health: how calcium, vitamin D and vitamin K work together [ADD LINK WHEN PUBLISHED]
 

Protein

 
Not just for healthy muscles, protein is also essential for your bones. You need it when you’re young and your bones are developing, and also throughout your life to maintain your bone density, especially as you get older.
 
In fact your bones consist of an organic protein matrix, 90 per cent of which is made of collagen (they also contain bone minerals such as calcium and phosphorus). Find out more about how protein helps your bones stay healthy by reading our article Bone health: the importance of protein. [ADD LINK WHEN PUBLISHED]
 
The current UK reference nutrient intake (RNI) for protein for adults is 0.75g protein per kilogram of body weight per day. However one of the most common questions vegetarians and vegans get asked is, how do you get enough protein? But not eating meat or fish doesn’t automatically mean you’ll run short of it. Vegetarians can get protein from dairy foods, but there are many plant foods that provide protein too, including:
 

• Tofu

• Quorn

• Seitan (wheat gluten)

• Tempeh

• Nuts and nut butters (peanuts, cashews, pistachios etc)

• Beans (soya beans/edamame, red kidney beans, butter beans, black beans etc)

• Chickpeas and green peas

• Lentils

• Seeds (chia seeds, hemp seeds, pumpkin seeds, linseeds, sunflower seeds etc)

• Plant-based milks and other dairy alternatives

• Grains (buckwheat, quinoa, spelt, wild rice, oats, amaranth, millet etc)

• Quinoa

• Wild rice

• Nutritional yeast

• Fruit and veg (eg broccoli, spinach, blackberries, sweet potatoes, artichokes, bananas)

 
Eating a wide range of plant-based protein sources is important, as not all sources are complete proteins – in other words, they don’t contain adequate levels of all of the nine essential amino acids that are the building blocks of protein (animal foods, however, do contain all nine). The idea is that, by eating lots of different protein foods you can make up what’s missing in one with another.
 
Plant foods that contain good levels of nearly all of the nine amino acids –  or nearly complete protein sources – include tofu and other foods made from soya beans, chia seeds, hemp seeds, nutritional yeast, buckwheat, amaranth and Quorn.
 
You can also boost your protein intake by adding protein powder to your food, or by drinking protein shakes (but make sure any you buy are suitable for vegetarians or vegans as some protein products can contain animal ingredients).
 

Magnesium

 
Magnesium is also needed for bone health as it helps keep bones rigid (70 per cent of your body’s magnesium is stored in your bones and teeth). Magnesium also helps convert vitamin D into the form that boosts calcium absorption in the body.
 
Magnesium is found in a wide range of healthy vegetarian and vegan foods, including:
 

• Quinoa

• Oats and oat bran

• Wholegrain rice

• Wheatgerm

• Nuts and seeds

• Tofu

• Beans and lentils

• Green leafy vegetables

• Avocados

• Bananas

• Soya milk

• Molasses

• Cocoa powder/dark chocolate

 
Despite the fact that magnesium is available in many foods, some people – whatever type of diet they eat – may not be getting enough (according to the NHS adult men need 300mg a day and women 270mg a day (xii)). Taking a magnesium supplement, however, can help make sure you’re getting the levels you need – ideally look for one that contains magnesium citrate, as it’s more readily absorbed than some other forms.
 

Vitamin C

 
Vitamin C contributes to normal collagen formation, which makes it an important bone health nutrient. The nutrient reference value (NRV) – the EU-recommended amount you need each day – for vitamin C is 80mg. You should be able to get that amount by eating a healthy balanced diet that includes lots of different fruits and vegetables. Some of the foods that contain good amounts of vitamin C include:
 

• Chilli peppers (red or green)

• Guavas

• Yellow peppers

• Blackcurrants

• Kale

• Kiwi fruit

• Brussel sprouts

• Papayas

• Lychees

• Broccoli

• Cantaloupe melon

 
If, however, you want to make extra sure you’re getting all the vitamin C your body needs, there are many supplements available in different formats including tablets, time-release capsules and powder.
 

Zinc

 
The mineral zinc has also been shown to play an essential role in bone metabolism and mineralisation (xiii). Indeed, scientists claim zinc is an essential mineral required for normal skeletal growth, and that it may also be able to promote bone regeneration (xiv).
 
If you’re male the amount of zinc you need each day is 9.5mg, while for females it’s 7mg. However many of the best sources are animal foods such as meat, shellfish and dairy foods. But there are plant sources containing zinc, including:
 

• Nuts

• Tofu, tempeh and miso

• Seeds

• Beans

• Chickpeas and green peas

• Quinoa

• Oats

• Wholemeal bread

• Corn

• Broccoli

 
If you think you may be at risk of not getting enough zinc in your diet you could try taking a zinc supplement – the citrate form of zinc is thought to be better absorbed by the body than other forms.
 

Building bone with exercise

 
Another important weapon in the battle against bone density decline – for everyone, not just vegetarians and vegans – is exercise.
 
Certain activities are particularly effective at helping to keep bones healthy: according to the Royal Osteoporosis Society, combining weight-bearing exercise with impact and muscle strengthening exercise is the best approach (weight-bearing exercise with impact involves being on your feet and adding an additional force or jolt through your skeleton through jumping or skipping, for instance) (xv):
 

• Low-impact weight-bearing activities include walking, marching, water aerobics, low-impact aerobics and stair climbing.

• Moderate-impact weight-bearing activities include skipping, hopping, jogging, running, hiking, team and racket sports, weight lifting or resistance training and dancing.

• High-impact weight-bearing activities include star jumps, tuck jumps,  track events, gymnastics, volleyball and basketball.

 
Muscle strengthening exercises include moves such as squats and lunges as well as exercises using weights like leg presses, chest presses, dead lifts and bicep curls. Heavy gardening – for instance, digging and shovelling – lifting and carrying children, wheeling a wheelchair and even carrying heavy bags of shopping can also improve your muscle strength.
 

How much exercise should you do?

Here in the UK, adults aged 19 to 64 are advised to do some type of physical activity every day. This includes:

• Muscle strengthening activities that work all the major muscle groups at least twice a week

• 150 minutes of moderate activity a week, spread out evenly over four or five days, or every day. Alternatively you could do 75 minutes of vigorous activity a week (examples include running, sports such as football, rugby, netball and hockey, stair climbing, aerobics, gymnastics, skipping and martial arts). Meanwhile you could also mix moderate and vigorous activity (or even short sessions of very vigorous activity such as lifting heavy weights, circuit training, interval running and spinning classes) to achieve your weekly target

• Reducing time spent sitting or lying down, including breaking up long periods of not moving with some activity

The recommendations are slightly different for adults aged 65 and older, who should also try to be active every day – even if they can only take part in light activities such as moving around their home, cleaning and dusting, standing up and making their bed. Other recommendations include:

• Muscle strengthening activities that work all the major muscle groups as well as exercises that improve balance and flexibility at least twice a week – these will help you feel more confident on your feet so that you are less likely to have a fall

• 150 minutes of moderate activity a week such as walking, riding a bike, dancing, playing doubles tennis or hiking (or 75 minutes of vigorous activity a week, or a combination of both)

• Limiting the time spent sitting or lying down, including breaking up long periods of not moving with some activity

There’s more information about staying active in our article Is exercise good for bone health?

Whatever your age, if you’re new to exercise or you haven’t been very active lately, start slowly, and build up your fitness levels gradually. Always speak to your GP before starting any new exercise regime if you have a medical condition.
 

Need more information?

 
Did you know it’s important for your bones to keep your weight in the normal range? In other words, try to avoid being underweight or overweight, as both have been linked with bone health problems (read our article Bone health: why weight matters to find out more about this).
 
You can also discover more about how your lifestyle can help keep your bones strong by reading How lifestyle affects bone health. The bone health section of our pharmacy health library is also a great place to go for lots more information, advice and tips.
 

References:

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2. The Future of Food: 10C. Available online: https://www.about.sainsburys.co.uk

3. Progress in reducing UK emissions 2023 Report to Parliament. Available online: https://www.theccc.org.uk

4. Tong TYN et al.. Vegetarian and vegan diets and risks of total and site-specific fractures: results from the prospective EPIC-Oxford study. BMI Medicine 18, article number: 353 (2020). Available online: https://bmcmedicine.biomedcentral.com

5. Our response to Oxford study which finds people on vegan diets may have more hip fractures. Available online: https://theros.org.uk

6. Iguacel I et al.. Veganism, vegetarianism, bone mineral density, and fracture risk: a systematic review and meta-analysis. Nutrition Reviews, Vol 77, Issue 1 January 2019, pages 1 - 18. Available online: https://academic.oup.com

7. Falchetti A et al.. The effects of vegetarian diets on bone health: A literature review. Front. Endocrinol (Lausanne) 2022 Aug 5;13:899375. Available online: https://www.frontiersin.org

8. Junwei Hu et al.. Association of plant-based dietary patterns with the risk of osteoporosis in community-dwelling adults over 60 years: a cross-sectional study. Osteoporos Int 2023 May;24(5):915-923. Available online: https://link.springer.com

9. Hsu E.. Plant-based diets and bone health: sorting through the evidence. Curr Opin Endocrinol Diabetes Pbes 2020 Aug;27(4):248-252. Available online: https://journals.lww.com

10. Vitamin D. Available online: https://www.nhs.uk

11. Vitamin K. Available online: https://www.nhs.uk

12. Vitamins and minerals - Others. Available online: https://www.nhs.uk

13. Amin N et al.. Zinc supplements and bone health: The role of the RANKL-RANK axis as a therapeutic target. J Trace Elem Med Biol 202 Jan;57:126417. Available online: https://www.sciencedirect.com

14. O’Connor JP et al.. Zinc as a Therapeutic Agent in Bone Regeneration. Materials 2020 May; 13(10): 2211. Available online: https://www.ncbi.nlm.nih.gov

15. Exercise and physical activity with osteoporosis. Available online: https://theros.org.uk

 

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