A Guide to Vegan Bone Health

Boost your vegan diet with bone health vitamins and nutrients, including calcium, vitamin D, and protein to protect your bones, according to the latest science. Learn all about this important issue in A Guide to Vegan Bone Health. 

Today, research shows us that well-planned vegan diets, which are void of all animal products, including meat, fish, poultry, dairy, and eggs, may be linked with numerous health benefits, including lower risks of heart disease, type 2 diabetes, obesity, and certain types of cancer. However, a shadow has been cast over one potential health concern: bone health. Some studies suggest that vegans may be at higher risk for bone fracture, but the evidence isn’t so clear-cut. Factor into the equation that confusion and myths abound over bone nutrition among the vegan community, which may lead to poorly planned diets. In the end, it may be the type of diet a vegan follows that matters more than being vegan itself. So, where does that leave you when it comes to making the most sensible choices for bone health nutrition? Most experts agree that it’s best to be cautious and stick with the current recommendations for bone nutrients, like calcium, vitamin D, and protein. 

Raising Vegan Bone Health Concerns 

Osteoporosis is a serious public health concern. This common chronic condition, marked by progressive loss of bone mineral density (BMD) and compromised bone strength, is associated with increasing risk of fracture over time. Over 200 million people worldwide suffer from this disease, (1) and 30% of all postmenopausal women in the US and Europe have osteoporosis. (2)

The process of bone mineralization (the laying down of minerals on the bone matrix) and resorption (when osteoclasts break down bone and release calcium into the blood) is complex and is affected by many factors, including nutrients, such as calcium, vitamins D and B12, zinc, protein, and omega-3 fatty acids, according to Katherine L Tucker, PhD, Professor of Nutritional Epidemiology at the University of Massachusetts Lowell. Tucker, who is a leading researcher on nutrition and bone health, says that unless one is very careful to ensure that all needed nutrients are obtained, it is easy for vegans to become deficient in these important nutrients.

“An animal-free diet can be so healthy and offer incredible benefits, but it is hard to deny that certain vitamins and minerals, such as vitamin D and calcium, may need to be supplemented in the majority of vegans. Bone health is a concern for all people, but especially those in certain categories that put them at higher risk. Any type of diet needs to be planned to avoid deficiencies in vitamins or minerals. Huge studies and meta-analyses have shown that vegans may be at a slightly higher risk for reduced bone density,” says Ginger Hultin, MS, RDN, CSO, past chair of the Vegetarian Nutrition Dietetic Practice Group. 

In a 2009 meta-analysis of studies looking at the effects of vegetarian diets on BMD, scientists found that, compared with omnivores, vegans had lower lumbar spine BMD, although the findings weren’t clinically significant. (3) And in the EPIC-Oxford study, fracture rates in the U.K. were compared in four diet groups: meat eaters, fish eaters, vegetarians, and vegans. While the fish eaters and vegetarians had similar rates of fractures as the meat eaters, the vegans had an incidence rate ratio of 1.15. (4)

However, not all research has found a greater risk. One intriguing study compared 105 Buddhist nuns, who were lifelong vegans due to religious rule, with 105 omnivorous women from monasteries in Ho Chi Minh City. They found that the median intake of calcium among vegans was lower, yet it was not correlated with BMD. (5)

Another concern is the impact of veganism on bone health among children and adolescents. “These are formative years for bone development, and a poorly designed vegan diet during that time may be a risk factor for bone health, among many, many other risk factors that need to be taken into consideration,” says Hultin. “Up to 90 percent of peak bone mass is acquired by age 18 in girls. Women who have a higher bone mass are at lower risk for osteoporosis later in life. Bone loss occurs with aging, but starting with a higher bone mass means less risk of losing so much bone that osteoporosis develops,” says Reed Mangels, PhD, RD, LDN, Nutrition Adviser for The Vegetarian Resource Group.

In a study of one vegan family, scientists found low dietary intake of calcium and vitamin D was linked to lower BMD, which was even more pronounced in the children, though it’s important to note the small size of this study. (6) In a larger study of 50 vegetarian and 50 omnivorous children aged 2-10 years, markers of bone turnover were found to be lower in vegetarian children compared to omnivorous children. In addition, calcium and vitamin D intake was two-fold lower in vegetarian children than omnivorous children. (7)

A recent meta-analysis “showed a 40% (confidence interval from -64% to 0%) lower calcium intake among vegan children but no difference in vitamin D intake (8).” Additionally, a single study included in the analysis “compared bone mineral content (BMC) of the lumbar spine and total body between vegan and omnivorous children” and found that “both were lower in the vegan group (9).“ 

This is important because it shows that adults are responsible for including good sources of calcium in vegan children’s diets. When no effort is made to include good sources of calcium in the diet, it puts children at risk for fractures later in life. Good sources of calcium to include in your child’s diet are mineral water, fortified plant-based milk, tofu, and green leafy veggies. The Academy of Nutrition and Dietetics’ current position supports vegan diets when appropriately planned to include all essential nutrients. The Academy addresses how vegan diets can be appropriate at every life stage, including childhood. (10) 

A separate study found that total lumbar spine bone mineral density scores in vegetarian children were lower, while absolute values of bone mineral densities didn’t differ from omnivorous children. Vegetarian children had lower leptin levels and less total body fat (11). 

Additionally, a cross-sectional study looked at a group of 36 vegans and 36 omnivores. It found that vegans had statistically significant lower concentrations of urinary calcium and higher levels of PTH (parathyroid hormone). Parathyroid hormone causes an overall loss of bone mass as it stimulates the resorption of bone while increasing osteoblast (bone-building) activity. The levels of the B12, B6, and thyroid-stimulating hormone (low TSH results in bone loss at a faster rate) were not statistically significant between the two groups (12). 

Bone Health is About Nutrients, not Veganism

While it may appear that vegans are at risk for lower BMD, when taking a closer look at the research it may be related to poor nutrient intake within a vegan diet. Some studies indicate that vegans have no greater risk of osteoporosis, as long as their intake of key bone nutrients, such as calcium, vitamin D and protein, is adequate.

The EPIC-Oxford study found that among subjects consuming at least 525 mg/day of calcium, the incidence rate ratios of fractures were 1.05 for fish eaters, 1.02 for vegetarians, and 1.00 for vegans. (4) Mangels explains, “This study found that vegans had a higher risk of fractures than did other vegetarians or nonvegetarians. When only vegans with calcium intakes above the UK Estimated Average Requirement for calcium were included in the analysis, there was no difference between any of the groups in terms of fracture incidence.”

“Bone health is a concern for vegans who have low intakes of calcium, protein and vitamin D. As long as vegans are eating a healthy diet, however, there is no evidence that they are at greater risk for bone disease,” summarizes Virginia Messina, MPH, RD and author of Never Too Late to Go Vegan. Tucker agrees, but adds, “The reality is that many vegans do not have adequate intakes of these nutrients.”

Lessons about Vegan Bone Health from Around the World 

Some experts point to the fact that vegans’ bone risk may be related to avoiding dairy products, often associated with bone health. But incidence of hip fracture—the most serious consequence of osteoporosis—has been highest in Sweden and North America worldwide, where dairy intake is prominent. Hip fracture rates have been lower in Asian and Latin American populations, where dairy intake is much lower. (13) According to a scientific review, calcium intake is much lower in Asia and Africa, mainly due to the very low intake of dairy products, yet the prevalence of osteoporosis is much lower in these countries than in the U.S. and Europe. (14) About 75 percent of the world’s population loses their lactose enzymes after weaning, which raises the question about whether dairy products are essential to bone health. 

However, the discussion is much more complicated than dairy products and bone health. Tucker explains that other diets from regions, such as Asia, that don’t typically contain calcium from dairy often include small fish with bones and calcium-set tofu. “One may be able to get along with somewhat less calcium than currently recommended if other bone building nutrients are adequate and in balance and in the environment of consistent weight bearing exercise,” adds Tucker.

Messina says, “Since these are ecological comparisons and often use hip fracture rates, which are affected by many factors, for comparison, I don’t think they tell us too much about diet and bone health. But it’s also clear that these populations have identified other good ways to meet calcium needs. Asian populations, for example, can get lots of calcium from soyfoods and the cruciferous greens that are common parts of their diets.”

Vegan Bone Myths 

Compounding the risk for bone health issues is a steady source of myths among the vegan community. “Unfortunately, there continues to be a lot of outdated advice regarding diet and bone health. Many vegans think that their lower protein intake protects bone health because older thinking was that protein caused calcium to be leached from bones. We know now that protein is important for strong bones and that vegans are not protected by the more alkaline nature of their diets. But because of this misinformation, many vegans believe that calcium isn’t important and they may not strive to include adequate amounts in their diet. Some vegans may also believe that they are getting enough vitamin D from sunlight, but it can be very difficult to get enough in certain climates,” says Messina.

Matt Ruscigno, MPH, RD, a speaker and author with a private practice specializing in plant-based nutrition in Los Angeles, says, “There are strong feelings in the vegan community, with reason, about how the dairy industry may influence calcium recommendations. Often vegans think that they don’t need to meet calcium requirements because they are avoiding animal protein, once thought to leach calcium from bones, but the research shows they still do.”

Other concerns involve a homespun trend that finds vegans making their own (unfortified) plant milks and avoiding fortified foods or supplements with the feeling “they can get everything they need from their diet,” which Mangels calls concerning. Homemade and newly popular brands of plant milks may be very low in protein, calcium and vitamin D, compared to fortified soymilks, which typically have very similar protein, calcium and vitamin D levels as dairy milk.

Calcium for Bone Health 

Of particular concern among vegans is calcium intake and its relationship to bone health, especially considering the lack of dairy products in their diets. It’s been well established that calcium is important for bone health. The body carefully regulates calcium levels; if the concentration in the blood, muscles or intercellular fluids is too low, the body takes calcium from the bones through resorption.

Recent research has created confusion over just how much calcium is needed, as well as the impact of supplementation. The 2011 Dietary Reference Intakes recommended an RDA of 1,000 mg for most adults 19 – 70 years of age, and 1,200 mg for women over 50 and men over 70. (15) However, this recommendation is not embraced around the world. The U.K. suggests adults get 700 mg per day (16) and the World Health Organization once recommended 400 – 500 mg of calcium for countries with a high fracture incidence to prevent osteoporosis, but updated their recommendation to 1000 mg for adults. (17) Throw into the mix that some (but not all) studies have linked calcium supplements with an increased risk for cardiovascular disease in elderly adults. Some health organizations are critical of the current recommendation for calcium, as well as the number of servings of dairy products in the USDA MyPlate. For example, the Harvard T. H. Chan School of Public Health’s Healthy Eating Plate does not include dairy products as an essential component of a healthy diet. (18)

So, how much calcium do you really need? Most of our experts agree that it’s best to be cautious and stick with the current RDA. “Until we have firm evidence to suggest otherwise, I recommend that vegans meet the RDA for calcium,” says Messina. “It’s also important to consider that research shows vegans may not be meeting their calcium needs,” adds Mangels.

Where should the calcium come from? This is another misunderstood area, according to Messina. “Generally, vegans should concentrate on foods with high absorption as their main sources of calcium. Bioavailability of calcium is excellent from cruciferous vegetables like turnip greens, collards, mustard greens and kale. But it is very poor from certain other greens, such as spinach, Swiss chard, and beet greens. It’s also good from soyfoods and fortified plant milks, but calcium is absorbed at much lower rates from other legumes and from nuts and seeds. If vegans are consuming large amounts of calcium-rich cruciferous vegetables they can probably get away with a little bit of a lower calcium intake since bioavailability of calcium from these vegetables is so high,” says Messina. Mangels reports that calcium from cruciferous, green vegetables is more bioavailable than the calcium in cow’s milk.

The Best Bone Health Supplements for Vegans

And what about calcium supplements? “Ideally, we should get our calcium from foods. But for those who find it difficult to meet needs it’s okay to make up the difference with a low-dose supplement—about 300 mg per day,” says Messina. Tucker adds that supplements are not ideal, and that a heavy dose all at once is not incorporated into our system. However, calcium supplements may still be appropriate for vegan clients.

Hultin notes that calcium was so “hot” and given routinely to most people not so long ago. She believes that fears over cardiovascular risks have changed all that, but that research in this area needs further exploration. She says, “Getting a full 1,000 mg in the diet can be challenging, so the use of some low dose supplementation and fortified foods can be very helpful in meeting the recommendations.”

Vitamin D for Bone Health

Vitamin D is important for bone health, too; it’s required for absorption of calcium. The Dietary Reference Intakes report recommends 600 IUs of vitamin D daily for adults 19 – 70 years of age. (15) While vitamin D is a shortfall nutrient for all Americans, it is even more of a concern for vegans. The EPIC-Oxford study found that vegans had the lowest intakes of vitamin D, compared to other diet patterns. (19) Since the major dietary sources of vitamin D is fortified dairy products, fish and egg yolks, it makes sense that vegans’ intake might be low. Vegan sources include fortified foods, such as plant milks, orange juice, and cereals; mushrooms exposed to light, sunlight exposure, and supplements.

Many experts recommend that vegans supplement the diet with vitamin D. “Vitamin D is critical. There are few food sources, and without fish or milk, it is very low in a vegan diet. While 10 minutes/day with exposed skin in good sunlight is fine in the summer, during winter months supplements may be needed to obtain sufficient vitamin D,” says Tucker. 

Protein for Bone Health 

A growing body of research points to the importance of protein in bone health, despite an older theory that lower protein intake protected calcium in bones. Excess protein may be associated with negative calcium balance, but low protein take has been associated with fracture. In the Framingham Osteoporosis Study, elderly men and women with lower protein intake had increased bone loss. They also found that higher intake of animal protein did not affect the skeleton adversely. (19) According to Tucker, who was a researcher in this study, “The highest protein intakes were protective. Over the long term, there appears to be increased calcium absorption and increased bone building with higher protein.”

Does it make a difference what type of protein vegans consume? Perhaps not, according to a 25-year study of wrist fracture risk among women, which compared meat consumption and plant protein consumption. In this study of nearly 2,000 peri- and postmenopausal women, scientists found that vegetarians who consumed the least vegetable protein were at the greatest risk for wrist fracture. However, increasing levels of plant proteins decreased wrist fracture risk, with a 68% reduction in risk in the highest intake group. Among those with the lowest vegetable protein consumption, increasing meat intake decreased the risk of wrist fracture, with the highest consumption decreasing risk by 80%. The scientists concluded that higher consumption of foods rich in protein were associated with reduced wrist fracture, which supports the importance of adequate protein for bone health. Yet, the similarity in risk reduction by vegetable protein foods compared with animal protein suggests that adequate protein intake is attainable in a vegetarian diet. (20)

Many vegans rely on fortified soymilk to replace milk in the diet, thus providing rich sources of calcium, vitamin D, as well as protein in the diet. In a 2014 article in the American Journal of Clinical Nutrition on bone nutrients for vegan diets, Mangels reported that bone health is often associated with the consumption of dairy products to provide bone health nutrients, yet plant-based sources also offer these bone-loving nutrients. (21) In the Adventist Health Study 2, scientists compared the bone effects of soymilk consumption and dairy consumption among 337 postmenopausal white women. Consuming at least 1 serving of soymilk per day was associated with improved bone health to a similar degree as dairy in vegetarian diets, leading the researchers to conclude that it may be a useful replacement, possibly related to its protein and calcium content. The protein content of unfortified soy milk is 3.27 g/100 g, compared with 3.15 g/100 g for whole milk; the calcium contents of unfortified and fortified soy milks are 25 mg/100 g and 123 mg/100 g, respectively, compared with a calcium content of 113 mg/100 g for whole milk. (22)

Alkaline Diet Patterns and Bone Health 

The potential bone impact of alkaline vs. acid diets has merited a great deal of attention in recent years. The theory is that some foods, namely meats, dairy, eggs, grains, and processed foods, produce more acid, while other foods, such as fruits, vegetables, and legumes produce more alkaline. But is there enough evidence to suggest that this scenario offers vegans greater bone protection?

Some research has suggested that high acid diets—typical in the Western diet—cause calcium to be released from the bones. However, one recent study found that high acid diets with adequate calcium intake did not impact BMD. (23) One study of German vegans found that diet did not affect acid-base homeostasis. (24) A cross-sectional study of young adult vegetarians, vegans and omnivores found that urinary pH was more alkaline among vegetarians and vegans, yet it was associated with BMD in omnivores only, and protein intake was associated with BMD only among vegan diets. The scientists concluded that plant-based diets are not detrimental to bone in young adults, and that diet prescriptions for bone health may vary among diet groups, including recommendations for increased fruit and vegetable intake for individuals with high meat intakes and increased plant protein intake for individuals who follow a vegetarian diet plan. (25)

Mangels says, “While some research finds that a more acid diet could lead to increased osteoclatic activity and increased bone resorption, more recent research suggests that the serum pH change that occurs in response to an acid-generating diet is not large enough to lead to increased bone resorption. Additionally, a vegan diet does contain foods that generate acid, such as soy products, corn, wheat and rice. The potential acid-producing effect of these foods may be offset by a high fruit and vegetable intake, since fruits and vegetables have an alkalizing effect. So, it seems to me that what’s important is to eat plenty of fruits and vegetables.”

“The greater use of vegetables in a healthy vegan diet will usually help the acid/base balance as opposed to a typical Western diet and this does offer some advantage. We have found that fruit and vegetable intake is protective of bone mineral density,” says Tucker. Hultin’s viewpoint is that the acid/alkaline theory discredits other important factors, including adequacy of vitamins and minerals and appropriate absorption. “Bone health is multi-factorial and even if alkaline/acid diets play a role, there are other important items to consider. The acid or alkaline nature of a diet is not enough to ensure bones will build and maintain adequate strength over time without taking in adequate bone building minerals,” adds Hultin.

Other Bone Nutrients 

Research is shining the light on other bone-protective nutrients beyond calcium, vitamin D and protein. “Nutrients, in addition to calcium, vitamin D, and protein, include phosphorus, magnesium, zinc, copper, manganese, vitamin C, vitamin B12, vitamin K, and potassium,” says Mangels.

Of particular interest is the impact of vitamin B12, which is low in vegan diets unless it is supplemented. Tucker explains that vitamin B12 is critical for DNA methylation and rebuilding of bone, and inadequacy has been related to fracture risk. “Vitamin B12 is only found to any extent in animal foods. This nutrient is very important for vegans and should be supplemented,” adds Tucker. In a study of German vegetarians, vegans, and omnivores, researchers found that low vitamin B12 status was related to increased bone turnover in vegetarian diet patterns, independent from vitamin D status. (26)

Growing research shows that omega-3 fatty acids have a role in bone metabolism, such as on calcium balance and osteoblast activity. (27) Intake of omega-3 fatty acids can be a problem for vegans, according to Tucker, since intake comes mainly from fish. “Plant sources are limited, but include walnuts and flax seeds, but the alpha-linolenic from these sources is not as efficient as the DHA/EPA from fish, so it is difficult to get enough. There are new vegan supplements of DHA available from algae, but few studies have evaluated them,” adds Tucker.

On the bright side, vegan diets are very high in whole grains, nuts, seeds, fruits, vegetables, and legumes, thus they are rich in many bone protective nutrients, such as vitamins C and K, magnesium, potassium, and antioxidant compounds. Tucker says, “This does help. We have seen protective effects of vitamin C and beta-carotene from fruit and vegetables. The magnesium and potassium from these, as well as whole grains and nuts are also protective. In addition to vitamins and minerals, a plant-based diet provides phytonutrients which are anti-inflammatory and this is also beneficial to bone.”

And, it’s important to consider lifestyle factors that can impact bone health, such as exercise and a healthy weight. “Vegans—and all people—should be paying close attention to other protective lifestyle factors, such as weight bearing physical activity and maintaining an appropriate body weight. Studies have shown that vegans often maintain a lower body weight than omnivores or vegetarians. Body stature and frame size can affect bone health with slighter folks, especially those who are underweight, being at greater risk for osteoporosis,” says Hultin.

Strategies for Protecting Bones

“I think it is best for vegans to meet with a dietitian to ensure that they are taking in adequate vitamins and minerals in the diet, assess risk factors on a personal basis, and discuss the appropriateness of supplementing. A dietitian can recommend any labs or tests that need to be done, such as vitamin D blood labs or bone density scans, and discuss other risk factors such as ethnicity, family history, body weight, use of bone depleting medications, or history of smoking or eating disorders. A dietitian can suggest diet and lifestyle factors to support bone health in vegans,” says Hultin.

Messina suggests, “Be knowledgeable about vegan sources of well-absorbed calcium and vitamin D. Most supplements are not vegan, so it’s important to identify ones that are either vitamin D2 or the harder to find vegan D3. Look for a diet rich in legumes, calcium-rich foods, and a daily source of vitamin D.”

Ruscigno says, “Weight bearing exercise is a very crucial part of bone health and I recommend all of my clients make working out a part of their health plan.”

Learn more about bone health in these blogs:

• How to Get Vegan Calcium Sources
• How Do I Get Vitamin D on a Plant-Based Diet?
• How to Get Complete Protein in a Plant-Based Diet?
• What are the Best Supplements for a Vegan Diet?

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