Background There is limited prospective evidence on possible differences in fracture risks between meat-eaters and vegetarians. We aimed to study this in a prospective cohort with a large proportion of non-meat eaters.

Methods In EPIC-Oxford, dietary information was collected at baseline (1993–2001) and subsequently around 2010. Participants were categorised into five diet groups at both time points (with 20,106 regular meat-eaters: ≥50 g of meat per day, 9,274 low meat-eaters: <50 g of meat per day, 8,037 fish-eaters, 15,499 vegetarians and 1,982 vegans at baseline for analyses of total fractures). Outcomes were identified through record linkage until mid-2016. Using multivariable Cox regression adjusted for socio-demographic, lifestyle confounders and body mass index (BMI), we estimated the risks of total (n=3,941) and site-specific fractures (arm, n=566; wrist, n=889; hip, n=945; leg, n=366; ankle, n=520; other main sites i.e. clavicle, rib and vertebra, n=467) by diet group over a mean of 17.6 years of follow-up.

Results Compared with regular meat-eaters, vegetarians had marginally higher risks of total fractures (hazard ratios 1.10; 95% confidence interval 1.00–1.20) and arm fractures (1.28; 1.01–1.63), while vegans had higher risks of total fractures (1.44; 1.21–1.72), arm fractures (1.60, 1.01–2.54) and leg fractures (2.06; 1.22–3.47). For hip fractures, the risks were significantly higher in fish-eaters (1.28; 1.03–1.59), vegetarians (1.27; 1.05–1.55) and vegans (2.35; 1.67–3.30) compared with regular meat-eaters. There were no significant differences in risks of wrist, ankle or other main site fractures by diet group. Overall, the significant associations appeared to be stronger before adjustment for BMI (e.g. 1.52; 1.27–1.81 in vegans for total fractures), and were slightly attenuated but remained significant with additional adjustment for dietary calcium and total protein.

Conclusion Overall, non-meat eaters, especially vegans, had higher risks of either total or some site-specific fractures, particularly hip fractures, than regular meat eaters. These differences may be partially related to lower BMI or lower dietary intakes of calcium and protein in the non-meat eaters. Further studies of non-European and contemporary populations are needed to determine the generality of these findings.