Abstract
Plant-exclusive dietary patterns have gained substantial popularity due to established cardiometabolic benefits and environmental sustainability; however, their impact on musculoskeletal health remains an area of clinical concern. This systematic review and meta-analysis quantified differences in bone mineral density (BMD) and incident fracture risk between adult vegans and omnivores. We systematically searched PubMed, Embase, Cochrane Library, and Web of Science up to December 2023 for observational studies evaluating BMD measured by dual-energy X-ray absorptiometry (DXA) or reporting incident fracture events. Random-effects models were employed to pool standardized mean differences (SMDs) for BMD and relative risks (RRs) for fracture incidence. Twenty-four studies involving 48,210 participants met the inclusion criteria. Vegans exhibited significantly lower BMD at the lumbar spine (SMD: -0.28; 95% CI: -0.39 to -0.17; p < 0.001) and femoral neck (SMD: -0.32; 95% CI: -0.44 to -0.20; p < 0.001) relative to omnivores. Furthermore, vegan dietary adherence was associated with a higher risk of total fractures (RR: 1.34; 95% CI: 1.15 to 1.56) and hip fractures (RR: 1.82; 95% CI: 1.38 to 2.40). Subgroup analyses revealed that fracture risk disparities were markedly attenuated in cohorts with mean dietary calcium intakes exceeding 700 mg/day and comparable body mass indexes. In conclusion, while strict veganism is associated with reduced BMD and elevated fracture risk, targeted nutritional strategies optimizing calcium, vitamin D, and protein intake can substantially mitigate these skeletal vulnerabilities within public health frameworks.
